LIBRARY OF CONGRESS. 



Sbelft 



'XI* 



UNITED STATES OF AMERICA. 






OCT 



20 V- 



PRACTICAL SURGERY: 



INCLUDING 



SDRGICAL DRESSINGS, BANDAGING, FRACTURES, 

DISLOCATIONS, LIGATDRE OF ARTERIES, AMPUTATIONS, 

AND EXCISIONS OF BONES AND JOINTS. 



BY ^ — 

■/ 

J. BWING MEAES, M.D., 

LECTUREK ON PRACTICAL SURGERy AND DEMONSTRATOR OF SURGERY IN JEFFERSON 

MEDICAL COLLEGE, PROFESSOR OF ANATOMY AND CLINICAL SURGERY IN THE 

PENNSYLVANIA COLLEGE OF DENTAL SURGERY, SURGEON TO ST. 

MARY'S HOSPITAL, GYNECOLOGIST TO JEFFERSON MEDICAL 

\) COLLEGE HOSPITM,, FELLOW OF THE AMERICAN 

SURGICAL ASSOCIATION, ETC. 






WITH 

FOXJB HUNDRED AND NINETY ILLUSTRATIONS. 






PHILADELPHIA 
TON, 

1885. 



BLAKISTON, SON & CO. 






Eutered accordiug to Act of Congress, in the year 1S85, by 

J. EWING HEARS, M.D., 
In the office of the Librarian of Congress, at Washington. 



COLLINS, PlilNTEK. 



(3n XHemoriam.) 

TO 

SAMUEL D. GROSS, M.D., LL.D. Cantab., 
LL.D. Edin., D.C.L. Oxon., 

PROFESSOR EMERITUS OF SURfiEUY IX JEFFERSON MEDICAL COLLEGE, 

AVHOSE EMINENT SERVICES 

AS 

AUTHOR, TEACHER, AND PRACTITIONER 

CONFERRED 

HONOR UPON HIS COUNTRY, HIS PROFESSION, AND HIMSELF, 

®|is look 

IS (5RATEFULLY INSCRIBED 



TITE AUTHOR. 



PREFACE TO THE SECOND EDITION. 



The author desires to express his appreciation of the 
favor with which the first edition of his work was received 
by both Practitioners and Students of Medicine. 

In the preparation of the present edition, he has endeav- 
ored, by the addition of new, and the revision of the original 
matter, to extend its usefulness. 

To the illustrations, for which acknowledgment was 
made in the preface to the first edition, he has added many 
others reproduced from the works of Gross, Agnew, 
Stephen Smith, Cheyxe, MacCormac, Pilcher, 
Hamilton, and Gray. 

Messrs. Gemrig and D. W. Kolbe & Son, of this city, 
and Tiemann & Co., of New York, have again placed him 
under obligations for the loan of cuts of splints and instru- 
ments. 



Philadelphia, 1429 Walnut Street, 
October, 1885. 



PREFACE TO THE FIRST EDITION. 



This book has been written in response to the request of 
students who have been from time to time under the in- 
struction of the author, and who have expressed a desire 
for a work which should embrace in a condensed form the 
subjects herein treated of. It has been the endeavor of the 
author to present these subjects in as concise a manner as 
possible, and at the same time to omit nothing which might 
be deemed necessary to render the instruction complete. 
While he has aimed to embody chiefly the results of his own 
experience as a teacher and as a practitioner, he has not 
hesitated to make use of the standard text-books on surgery 
and of such works as are devoted to the consideration of the 
special topics presented in this. 

With a few exceptions, the illustrations are reproductions 
from the works of Gross, H. H. Smith, Stephen Smith, 
AsHHURST, Packard, Maunder, Heath, Bellamy, and 
Bernard and Huette. The anatomical relations of the 
arteries are largely those which are given in " Gray's Anat- 



Vlll PREFACE TO THE FIRST EDITION. 

omy," tlie correctness of which has been verified by dissec- 
tions and operations. 

Messrs. Gemrig and Kolbe, instrument- makers, of this 
city, and Messrs. Stholmann, Pfarre & Co., of New York, 
have placed the author under obligations for the loan of cuts 
of instruments. 

To Dr. John W. Barr his thanks are especially due for 
valuable aid in correcting the proof of the work. 



Philadelphia, 1429 Walnut Street, 
October, 1878. 



CONTENTS. 



PART I. 
SURGICAL DRESSINGS. 

PAGE 

Tompresses .......... 13 

Plasters 20 

Poultices or Cataplasms ....... 23 

Methods of Irrigation 25 

Sponges 27 

Instruments used in Dressing Wounds . • . . 29 

Dressing a Wound 32 

The Antiseptic System of Dressing Wounds ... 35 

Agents employed in diiferent Antiseptic Methods . . 47 

Important points involved in Treatment of Wounds . . 58 



PART II. 
BANDAGING. 



The Simple Bandage or Roller 65 

for the Head, Body, Extremities 67 

for the Hand 68 

Bandages of the Head 72 

of the Trunk 79 

of the Extremities ........ 89 

of the Superior Extremity ...... 

of the Inferior Extremity . . . . . • • &• 



89 



X CONTEXTS. 

PAGE 

General Bandages 98 

The Compound Bandages 102 

Mayor's System of Handkerchief Dressings .... 104 

Immovable Bandages 108 



PART III. 
FRACTURES. 



Complete Fractures 117 

Incomplete Fractures 119 

Causes of Fracture . . . . . . . .121 

Symptoms of Fracture 122 

Diagnosis of Fracture ... . . . . . .124 

Prognosis in Fractures 125 

Treatment of Fractures 128 

of Complicated Fractures 144 

of Compound Fractures 145 

of Fractures united with Deformity ..... 147 

Ununited Fracture or Pseudarthrosis ..... 149 

Special Fractures 152 

Cranium .......... 152 

Face 155 

Trunk 164 

Upper Extremity ........ 173 

Lower Extremity ........ 226 



PART IV. 
DISLOCATIONS. 

Traumatic Dislocations 299 

Pathological Dislocations ....... 300 

Congenital Dislocations 301 



CONTENTS. 



XI 



Causes. of Dislocation . 

Symptoms of Dislocation 

Diagnosis of Dislocation 

Prognosis 

Treatment . 

Complicated 

Compound . 

Old 

Special Dislocations 

Head and Face 

Upper Extremity 

Pelvis 

Lower Extremity 



PAGE 

301 
305 
307 
308 
309 
313 
314 
317 
320 
320 
339 
412 
416 



PART V. 

LIGATURE OF ARTERIES. 

Positions of the Knife 476 

Incisions 478 

Closure of Wounds 479 

Sutures .......... 479 

Needles 481 

Operations upon the Living and Dead Subjects . . . 482 

Instruments used in the Ligature of Arteries . . . 484 

Operations for the Ligature of Arteries .... 486 

Ligature of Special Arteries ...... 493 



PART VI. 

AMPUTATIONS. 

Instruments used in Amputations 

Methods of controlling Hemorrhage in Amputations 

Methods of Amputation ..... 



571 
576 
580 



Xll 



CONTENTS. 



PAGE 

After-treatment in Amputation . . . . . .597 

Affections of the Stump ....... 600 

Synclironous Amputation 605 

Re-amputafions . . . ' 607 

Intra-uterine Amputations 607 

Constitutional effects after Amputation .... 607 

Special Amputations ........ 610 

Lower Extremity ........ 610 

Upper Extremity 662 



PART VII. 
EXCISIONS OF BONES AND JOINTS. 



Conditions demanding Excision 

Contra-indications in 

Process of repair after 

Instruments used in 

Incisions employed 
Special Excisions 

Cranium . 

Face 

Trunk 

Upper Extremity 

Lower Extremity 



699 
699 
700 
703 
709 
709 
717 
731 
735 
762 



Index 



PRACTICAL SURGERY. 



Practical Surgery may be divided conveniently into 
two ^Kirts : First, that part which relates to the preparation 
and application of surgical dressings — mechanical ; and, 
second, that which embraces surgical operations — the use 
of cutting instruments and the production of wounds — 
operative. 



PART I. 

SURGICAL DRESSINGS. 

Under this term may be included all appliances which 
are employed in the treatment of wounds, made either by 
tiie surgeon in performing operations, those which are caused 
by injuries, or those conditions which are the results of mor- 
bid processes. 

They consist, in general, of Compresses, Plasters, Poul- 
tices, Bandages, and Splints, and are prepared in such 
manner as to fulfil the indications presented in each indi- 
vidual case. 

Compresses are folded pieces of various materials, such 
as lint, charpie, cotton, wool, oakum, muslin, linen, etc., 
which are placed upon a part and retained by means of 
bandages. 
2 



14 SURGICAL DRESSINGS. 

Lint is a soft, flocculent substance prepared by scraping 
the surface of a piece of old linen. That known as patent 
lint is made by machinery. Recently another form of lint, 
made from paper and called paper-lint, has been prepared, 
which possesses remarkable absorbent properties. Lint, 
rendered antiseptic by boracic acid and other agents, is also 
found in the shops. 

Charpie This consists of a mass of loose sliort threads, 

made by separating pieces of linen or muslin measuring four 
or five inches square. It may be either fine or coarse, ac- 
cording to the character of the material employed. It can 
be arranged into a variety of forms, so as to be adapted to 
the various kinds of wounds ; these are called tents, pledgets, 
etc. 

Cotton-wool In the raw state or arranged in sheets, this 

material is used as a dressing. In this respect, its value has 
been increased recently by the introduction of various pro- 
cesses which are employed to render it antiseptic, and give 
to it absorbent properties. It can be made hygroscopic by 
boiling it in lye. In addition, cotton charged with boracic 
acid, carbolic acid, benzoic acid, subsulphate of iron, per- 
chloride of iron, tannic acid, corrosive sublimate, iodine and 
iodoform, forming the borated, carbolated, benzoated, haemos- 
tatic or styptic, tannated, corrosive sublimate, iodized and 
iodoform preparations are now employed largely in surgical 
dressings. Absorbent cotton takes up fifteen times its weight 
of water. When the cotton-wool, which has not been ren- 
dered antiseptic, is used, care should be taken to see that it 
is clean and free from particles of dirt. The eggs of the fly 
are sometimes deposited in it, and under the action of the 
heat developed when in contact with the surface of the body 
these develop into maggots. 



SURGICAL DRESSINGS. 15 

Wool Finely carded wool has been employed as a dress- 
ing ; it possesses no advantage over cotton, and is more 
expensive. 

Oakum — This material is made by untwisting and sepa- 
rating pieces of old tarred rope ; it is subsequently cleaned, 
and forms an excellent dressing ; is cheap, readily obtain- 
able, and possesses decided advantages by virtue of the tar it 
contains. Oakum has been rendered antiseptic in the same 
manner as cotton, forming various preparations. 

Jute — A substance resembling hemp. It is prepared for 
use as a surgical dressing by cleansing it thoroughly, and 
then treating it with carbolic acid, resin, glycerin, and alco- 
hol, in the following proportions : To each pound of jute add 
carbolic acid 2J ounces (50 gram.) ; resin, 6J ounces (200 
gram.) ; glycerin, 8;^ ounces (250 gram.) ; and alcohol, 18J 
ounces (550 gram.). In order to reduce the cost of prepa- 
ration, benzine can be substituted for the alcohol. It has the 
power of absorbing from four to six times its weight of water. 
It should be soft and silky, and free from coarse fibres. As 
the carbolic acid disappears rapidly from it, that used should 
be freshly made. It retains corrosive sublimate ibr a longer 
period. Sublimated jute is made by macerating twelve 
hours in a solution of corrosive sublimate 1 to 1000 parts of 
water, and glycerin 50 parts. It serves in general the same 
purpose as oakum. 

Tenax or Tow A preparation of flax or hemp is also 

used as a dressing ; it is not as available as oakum. 

Gauze — This material is now used much as a dressing, 
owing to its porous character, which permits of the free 
escape of discharges from the surfaces of wounds. Dairy or 
cheese cloth is usually selected, and it is rendered antiseptic 
by different agents, as carbolic acid, boracic acid, corrosive 



16 SURGICAL DRESSINGS. 

sublimate, iodoform, etc. Its cost is so slight that it can be 
used as a substitute for the ordinary dressings. Mosquito 
netting, which has not been dyed, can be used in place of 
the cheese cloth if desirable. 

Glass-wool. — This substance consists of finely spun strands 
of glass, and has been suggested recently as an article of 
dressing. Its place can be supplied by other dressings. 

Peat This substance possesses great absorbent proper- 
ties. It was first employed mixed with iodoform as a dress- 
ing in the hospitals at Kiel, in Germany ; two varieties, the 
white and black, are used ; sometimes they are mix«d, four 
parts of the former to one of the latter. It is said to absorb 
sixteen times its weight of water. 

Wood-wool This substance is obtained from the pulp of 

wood during the process of paper manufacture. It possesses 
great absorbent qualities, and is used in the same manner as 
peat. 

Moss The ordinary moss of the forests, introduced by 

Dr. Weir, of New York. It should be dried in an oven to 
kill the insects it may contain, and can then be treated and 
used in the same manner as jute, peat, and the wood-wool. 

Sawdust Dr. A. G. Gerster, of New York, has em- 
ployed sawdust, wliich has been soaked in a solution of cor- 
rosive sublimate (1 to 500) and afterwards dried, and has 
found that it gave great satisfaction as a dressing. 

Bran. — This substance has been long used as a dressing 
in compound fractures. Recently it has been rendered anti- 
septic by carbolic acid, and in this way its value has been 
increased. It can also be treated with a solution of corro- 
sive sublimate. 

Dry Earth. — Clay dried and finely powdered was intro- 
duced by Dr. Addinell Hewson, of Philadelphia, as a dress- 



SURGICAL DRESSINGS. 17 

ing some years since. It has also been treated with carbolic 
acid and corrosive sublimate solutions. 

Charcoal. — Charcoal in the powdered state has been long 
employed as a wound-dressing. 

Sand Kiimmell, of" Hamburg, has recently introduced 

this substance as a dressing, using for that purpose white 
quartz-sand. It is prepared by passing it through a fine 
sieve, and then heating it in an oven in a covered pan for 
several hours. Sublimated sand is prepared by mixing 
10,000 parts of sand in 10 parts of corrosive sublimate and 
100 parts of ether, and should be kept in glass-stoppered 
bottles. It is used to fill wound cavities, being covered 
with the sublimated gauze, which is held in place by a gauze 
bandage. 

Coal-ashes. — The absorbent properties of finely sifted coal- 
ashes render them serviceable for the purpose of dressings. 
Tlieir antiseptic power can be increased by saturating with 
an antiseptic solution, as corrosive sublimate. Kiimmell has 
employed the ashes in the shape of cushions, which are of 
varying sizes, to adapt them to different wounds, and are wet 
with the antiseptic lotion before being applied. 

Spongio-piline is made by felting together layers of lamb's 
wool and sponge, and coating one of the surfaces with rub- 
ber, which renders it impermeable to moisture. This is an 
elegant preparation, but too expensive for general use. 

Muslin and Linen Pieces of old muslin or linen are 

most frequently used as articles of dressing,, and are fre- 
quently quite as serviceable as the more costly materials. 

The various articles of dressings can be formed into dif- 
ferent shapes, as the square, oblong, triangular, cribriform, 
or graduated compress, the Maltese cross, etc. The forma- 

2* 



18 



SURGICAL DRESSINGS. 



Fig. 1. 



tion of the square, oblong, and triangular compress is quite 
easy, the name indicating the form. 

The Cribriform Compress is made by folding a square 
piece of muslin four or five times on itself, and then nicking 
the border in a number of places with the scissors. When 
opened, it will present a cribriform appearance. The open- 
ings whicli are made permit the 
free escape of discharges (Fig. 1). 
The Maltese Cross derives its 
name from the sliape, and is made 
by folding a square piece of the 
material from which it is to be 
formed into an oblong square, fold- 
ing this into a smaller square, then 
into a triangle so as to bring the 
free edges in contact, and slitting 
the base of this triangle to two-thirds of its extent, the in- 
cision beginning at the end formed by the joining of the free 
edges (Fig. 2). On opening the piece it will be found tliat 
a regular Maltese cross has been formed (Fig. 3). 



M I f M > 4 ' 

ft! Ml ) t p 

i ) f i 1 i i S * 

! i » M } M 

[ t I n I it , 

» f M J M f 

I M M M M 
If M. * 5 J f ; 



Fig. 2. 



Fig. 3. 





The Half Maltese Gross is formed by folding an oblong 
square into a smaller square, then into a triangle, and incis- 
ing the base as above described (Fig. 4). 



SURGICAL DRESSINGS. 



19 



These forms are useful in dressing stumps after amputa- 
tions. 

The Graduated Compress consists of a number of folds, so 
arranged that each succeeding fold covers about one-half of 
that preceding it (Fig 5). 



Fiff. 4. 




Fig. 5. 




The Pyramidal Compress is prepared by sewing together 
square pieces which gradually de- 
crease in size, so placed as to form 
a pyramid (Fig. 6). These are used 
for making pressure. 



Fig. 6. 



It is frequently desirable to cover 
dressings with an impermeable 
covering, so as to retain moisture 
or prevent the escape of discharges 
upon the bedclothes or clothing. 

Among these articles are oiled silk, waxed paper, oiled paper, 
and gum tissue or rubber cloth. 

Oiled Silk is made by coating pieces of silk with layers 
of boiled oil, containing the oxide of lead to render it dry. 
This was formerly much employed; lately it has been sup- 
planted largely by less expensive articles. 

Waxed Paper — This can be readily prepared by passing 
sheets of strong tissue paper through melted white or yellow 



wax or paraffin, and then hanging tliem up to dry. It serves 



20 SURGICAL DRESSINGS. 

the same purpose as the oiled silk, is quite inexpensive, and 
can be thrown away after being used. A few drops of lin- 
seed oil added to the melted wax will render the coating less 
brittle. 

Oiled Paper is made by brushing sheets of paper with 
boiled oil, which has been reboiled with oxide and acetate 
of lead, sulphate of zinc, and burnt umber. 

Gutta Percha or Gum Tissue is a liglit and elegant article, 
and is in general use in the antiseptic dressings. 

Rubber Cloth. — This material, prepared in very thin 
sheets, may be employed as an impermeable covering. 

Plasters. — Adhesive Plaster (Emplastrum Resinas). 
This plaster is found already prepared in the shops, spread 
upon cotton, twill, or swans' down. Care should be taken 
to select that which has been recently made ; when old it 
becomes dry, cracks, and loses its attachment to the cloth 
upon which it has been spread. 

In cutting strips, the scissors should be applied with the 
blades very slightly open^ using the cutting edges of the 
points only, and dividing the plaster lengthwise, and not 
crosswise. The division should be effected by pushing the 
scissors along, and not by closing the blades, the piece being 
firmly held by an assistant (Fig. 7). If cut crosswise, the 
cloth stretches, and thus interferes with proper application 
of the strips. The width and length of the strips will vary 
according to the wants of each case ; as a rule, they shoidd 
be three-quarters of an inch wide, and long enough to ex- 
tend three inches beyond the edges of the wound. In ap- 
plying them, they should be placed first in contact with the 
central and the most dependent part ol' the wound, in order 
to draw it up and afford support from below upward. Small 



SURGICAL DRESSINGS. 



21 



triangular pieces may be cut out of the strips at the points 
of contact with the surface of the wound, so as to permit 
the discharge to escape. The strips may be made to adapt 
themselves smoothly and evenly to a round or irregular sur- 
face by nicking the edges. Before applying the strips of 
plaster, it is necessary that 

they should be heated, and ^^^' '' 

the most efficient, and, at 
the same time, most con- 
venient method is to place 
the cloth side of the strips 
in contact with the surface 
of a tin can or bottle con- 
taining hot water ; in this 
way the surface is equably 
^heated and softened, so as 
to adhere to the >-kin. At- 
tempts to heat adhesive 
strips over the gas-light, 
candle-light, spirit-lamp, 
over the surface of the 
stove, by dipping them in 
hot water, or by applying 
such an agent as chloro- 
form, usually result in fail- 
ures to secure that equable 
heating and softening of 

the adhesive surface which is so desirable in securing a firm 
attachment to the surface of the skin ; besides, the strips are 
liable to be scorched and discolored, and thus detract from 
the neat appearance of the dressings. 

In order to remove the adhesive strips, warm water should 




22 SURGICAL DRESSINGS. 

be applied to the surface by means of a sponge or cloth. 
The ends should then be taken hold of, and the strip gently 
raised from each side of the wound to within an inch of the 
line of the incision (Fig. 8). The edges of the wound should 




now be supported by the thumb and index finger of one 
hand, while the strip is lifted in a vertical direction from 
the part. Sufficient space should always be left between the 
strips to permit free escape of the discharges. 

In order to avoid giving pain to patients, and disturbing 
the wound in removing the strips of plaster from surfaces, 
especially those which are covered with hair, the late Mr. Cal- 
lender, of London, employed the simple expedient of cutting 
out the spaces over the dressing at the points the strips left 
the wound and passed on to the surface of the skin. In re- 
newing the dressing the divided plaster is rejoined by strips 
laid over the first applied; this can be repeated, leaving the 
strips first applied still adherent to the skin until the wound 
is healed. 

A very good form of adhesive plaster has been introduced 



sukCtICal dressings. 



23 



recently, which is " self-adhesive." The heat of the body 
is sufficient to render it firmly adherent. It comes in sheets 
or in strips of various lengths and widths rolled on spools, 
and is thus prepared very conveniently for use. 

Besides the officinal adhesive plaster, other varieties are 
employed, such as Isinylass Plaster, Court Plaster, etc. 
These require to be moistened, and not heated, in order to 
be made to adhere to the surface, and are more desirable 
applications in wounds of the face and head. 



Fig. 9. 



Poultices, or Cataplasms, are soft, moist substances 
which are employed in the treatment of wounds (Fig. 9). 
They are designated as the emol- 
lient, astringent, stimulating, fer- 
menting, rubefacient, narcotic, etc. 

The Emolient Poultice is that 
form most commonly used, and 
may be made of bread and milk, 
corn meal and water, flaxseed 
meal, ground elm bark, or any 
unirritating substance. The flax- 
seed or linseed meal poultice is 
made thus : A quantity of recently ground meal is put into 
a basin which has been scalded, and boiling water is poured 
into it gradually, the mixture being well stirred, until it 
acquires a consistence which will prevent its running out 
when the basin is inverted. It is then to be spread with a 
spatula or table knife, to a thickness of one-quarter to three- 
quarters of an inch, upon a piece of strong muslin of the 
proper size, a border of an inch in width being left un- 
covered. The corners of the cloth are now incised with the 
scissors, and the borders folded over so as to form a margin, 



r— — -Ti 




!■: ! •"' ^:^'A.:.^:■■Kl\•^ 


^^M 


— ^— " - 


p-==-=---:-rt 


r 1 



24 SURGICAL DRESSINGS. 

which will prevent the adhesion of the edges to the surface, 
and also the escape of the contents of the poultice. A piece 
of fine white gauze or mosquito netting (that which has been 
dyed should not be used) may be placed over the poultice 
to prevent it from adhering, and folded down with the edges 
of the cloth. A few drops of olive oil may be poured over 
the surface to soften it, or any article with which it is 
thought desirable to medicate the poultice, as tincture of 
opium, etc. 

In order to retain the moisture in the poultice, it should 
be covered with a piece of oiled silk, or with waxed paper. 
As a rule, poultices should be renewed twice in twenty- 
four hours — more frequently if the conditions of the case 
demand it. 

The Astringent Poultice can be made by adding the 
astringent substance to the linseed meal or bread and milk 
poultice. 

The Stimulating Poultice may be made of various sub- 
stances, as grated boiled carrot, horseradish, garlic, black 
pepper, brine and corn meal, etc. 

The Fermenting Poultice is usually made by mixing corn 
meal with yeast or porter. 

The Rubefacient Poultice is made by mixing flour of 
mustard with water until a proper consistence is obtained. 
Its strength may be reduced by the addition of flour, in the 
proportions of one-quarter or one-half. Vinegar should not 
be used in preparing these poultices, as it destroys their 
rubefacient properties. 

A poultice of great value in the treatment of cases of hos- 
pital gangrene may be made of equal parts of powdered 
animal charcoal and brown sugar. 

The Iceland moss instantaneous poultice has been lately 



SURGICAL DRESSINGS. 



25 



introduced, and is found for sale in the shops. It is claimed 
to possess special advantages in not undergoing fermentation 
and in the ease with whicli it can be saturated with medi- 
cated lotions. 

Poultices may be confined to the part by a few turns of 
a roller or by broad strips of adhesive plaster. When ap- 
plied to such a part as the breast, they should be cut in a 
circular form and the circumference nicked to the extent of 
an inch or more in order that they may adapt themselves to 
the surface. 

Methods of Irrigation It is frequently necessary, 

in the treatment of surgical affections, to apply water dress- 
Fig. 10. 




26 



SURGICAL DRESSINGS. 



ings, or heat or cold either in the dry or moist form. The 
simplest method in the moist form is to apply compresses 
wrung out in warm or cold water ; this is inconvenient, 
however, and does not secure a uniform effect. A simple 
and efficient plan is to put a piece of lamp-wick or a number 
of threads into a reservoir of water placed some distance 
above the level of the patient's body, which, acting as a 
siphon, conveys the fluid uniformly over the part. 

Dry cold and dry heat may be conveniently applied in 
the form of the rubber bags or thin metallic boxes — con- 
taining in the one case ice, and in the other hot water. The 
most efficient method of applying dry cold or heat is by 



Fig. 11. 




SURGICAL DRESSINGS. 27 

means of the rubber tubing as suggested by M. Petitgand. 
A flexible rubber tube sixteen to twenty feet in length and 
one-half of an inch in diameter is applied around the part 
in a spiral manner and held in position by a few turns of a 
roller or by adhesive strips. The walls of the tube should 
be not more than a line in thickness, and the end which is 
placed in the reservoir should have a metallic cap heavy 
enougii to sink it, and so arranged that the water can have 
free access to the tube. The other end should be provided 
with a stopcock and nozzle, so that the floAv of the water 
tlirouorh the tube can be regulated. The reservoir of water 
is placed above the level of the patient, as in the other 
forms. In all cases where water-dressings are employed, 
the bed should be protected by a rubber cloth or other 
suitable material (Figs. 10 and 11). 

Sponges. — These play an important part in all surgical 
operations and in the dressing of wounds. They should be 
selected with great care, and none but those which are of 
fine and soft texture should be used. When obtained in the 
shops, it will be found that, as a rule, they contain particles 
of sand and sometimes other foreign substances. Before 
using, therefore, they should be thoroughly beaten, washed, 
and allowed to soak for a number of hours, if practicable. 
When the calcareous particles cannot be entirely removed 
by washing, the sponges should be placed for a short time 
in a dilute solution of hydrochloric acid, one part to thirty 
of water, which will dissolve the particles, and then washed 
in an alkaline solution (aqua? ammonias fort., 5ij to Oj of 
water) to neutralize any acid remaining in the meshes. 
Sometimes sponges contain prickles derived from plants which 
grow in contact with them, and with which they become 



1^8 SURGICAL DRESSINGS. 

thoroughly irrpreojnated during tlie process of cleaning and 
preparing for market. During the use of tliese sponges the 
prickles penetrate the fingers of the surgeon, and must, of 
course, cause much irritation of the wounded surfaces upon 
which the sponges are placed in operations ; care should be 
taken to reject all sponges containing these substances. It 
is of great importance that they should be perfectly free from 
all foreign matter, and should be made scrupulously clean 
before using. It is a good and safe rule to have neiv sponges 
for each patient, which will be used only for that person. 
When new sponges cannot be procured, those which have 
been used can be thoroughly cleansed by soaking them in 
a four per cent, solution of permanganate of potassium, 
then in a twenty-five per cent, solution of sulphurous acid, 
and finally washing thoroughly in water ; or, they may be 
well washed in a solution of carbolic acid (1 to 20), or of 
corrosive sublimate (1 to 1000) and kept constantly in the 
solution. Under no circumstances should sponges which 
have been employed in dressing erysipelatous or gangrenous 
wounds, or those of a contagious character, be used in dress- 
ing the wounds of another patient. If this precaution be 
neglected, the gravest consequences may ensue in the con- 
veyance of infectious diseases. 

In dressing a wound the sponge should never be placed in 
contact with the ojranulating surfaces. The water should be 
allowed to flow upon the surfaces by compressing the sponge 
raised some distance above. About the edges of the wound 
and adjacent surfaces the sponge should be applied gently, 
so as to remove discharges. When operations are performed 
in connection with the cavities of the body, or in cases of 
necrosis, the sponges should be counted before the operation 



SURGICAL DRESSINGS. 29 

and after its completion^ in order to avoid the grave error of 
leaving any, or pieces of any, in the cavity. Fatal results 
have resulted and heavy damages have been paid on account 
of failure to attend to this injunction. 

In using the sponges in operations they should be tho- 
roughly squeezed out so as to absorb readily the blood, and 
should l)e pressed upon the denuded surfaces and not rubbed. 
They should never be used for removing the blood from the 
floor after operations, or for any purpose other than that for 
which they were intended. 

INSTRUMENTS USED IN DRESSING AVOUNDS. 

The instruments which are usually required in applying 
or removing dressings are few in number, and consist of a 
pair of Dressing Forceps, Dissecting Forceps, and Scissors. 

The Dressing Forceps are shaped like the ordinary scis- 
sors, terminating in rounded, spoon-shaped ends, the edges 
and inner surfaces of which are serrated. They are used to 
seize hold of dressings and remove them from the surface of 
wounds (Fig. 12). 




The Dissecting Forceps are employed to remove minute 
pieces of dressing, foreign bodies, etc., doing this more 
readily than the dressing forceps (Fig. 13). 



.q* 



30 



SURGICAL DRESSINGS. 
Fi-. 13. 




The Scissors may be either straight or curved, and are 
used to give shape to the articles of dressings, etc. They 
should not as a rule be used to divide the tissues, as they 
produce a contused edge in the wound which interferes with 
the union (Figs. 14, 15). 

Fiff. 14. 




Fi{?. 15. 




These are found in the Pocket Case, with other instru- 
ments which are used in operations and in the treatment of 
disease (Fig. 16). 

As it is quite desirable to have the Pocket Case small in 
size and not too bulky, and yet contain all of the instru- 
ments required, some tact has been displayed in arranging 
them. That known as Professor S. D. Gross's case con- 



SURGICAL DRESSINGS. 



31 



tains : One Scalpel and Straight Bistoury ; two Curved 
Bistouries, probe and sharp-pointed ; one Tenotome and 
Tenaculum ; one pair of Artery and Needle Forceps com- 
bined ; one pair of Scissors ; one pair of Polypus and Dress- 
ing Forceps ; one pair of Dissecting Forceps ; one -Exploring 
Needle; one male and female Catheter; one Porte-caustique; 
one Gross's Ear Instrument ; one Grooved Director ; one 
pair of Probes ; one half-dozen Needles, and one skein of 
Silk. The cutting instruments are double-bladed, with slide 




32 



SURGICAL DRKSSTNGS. 



locks to secure the blades, either opened or closed (Figs. 
17, 18). Dr. W. W. Keen has suggested a modification of 



Fiz. 17. 




Fi^. 18. 




the pocket case which materially reduces its size, and at the 
same time adds three instruments. As arranged by him it 
measures 4^x2^x1^^ inches, and contains in addition a 
hypodermic needle, a thermometer, and a tubular needle. 



DRESSING A WOUND. 

In order to dress a wound the following articles and in- 
struments should be at liand : Water, both hot and cold ; 



SURGICAL DRESSINGS. 33 

receptacle for the soiled dressings, basins, sponges, lint or 
other material to form compresses, syringes, including a 
fountain syringe, rubber-clotli to protect the bed, towels, 
bandages, adhesive plaster, tin can containing hot water to 
heat the plaster, needles, pins, and pocket case containing 
dressing forceps, dissecting forceps, and scissors. 

A sufficient number of assistants should always be present, 
in order that the dressings may be removed and applied 
with as little dehiy as possible. Usually three are required : 
one to support the part, one to attend to the sponges and 
supply of water at proper temperature, and a third to hand 
the dressings and instruments. Before exposing the wound, 
the assistants should be assigned to their respective posi- 
tions, the dressings prepared, and everything in readiness. 
The rubber cloth should be placed so as to protect the bed, 
and the part lifted by the assistant and held in a comfortable 
and easy position. The soiled dressings should be removed 
carefully and placed in a covered receptacle and taken from 
the room. The wound should be cleansed by allowing the 
water to flow over it, from the tube of the fountain syringe, 
or squeezed out of a sponge held some distance above its 
margin, or vertically over it. If cavities exist, these can 
be thoroughly cleansed by throwing water into tliem with a 
syringe, being careful .to avoid giving too much force to the 
stream. The borders of the wound and adjacent surfaces 
should be gently wiped with the sponge, wnth regular and 
even motions^ carrying it toward the edges so as not to cause 
them to separate or to pull upon the sutures if they still re- 
main. Short, jerking movements should be avoided in using 
the sponge, as they give pain and are liable to cause separa- 
tion of the edges of the wound. The sponge should not be 
placed in contact witli the denuded surfaces. Collections of 



34 SURGICAL DRESSINGS. 

pus can be removed by a gentle stream of water thrown by 
the syringe, and foreign bodies can be picked off readily with 
the dissecting forceps. 

When cleansed, the borders should be dried by pressing 
a clean, soft towel upon them, care being taken to avoid 
bringing it in contact with the wound. If required, the 
adhesive strips already cut should be applied in the manner 
directed above (page 21). The compress, upon which has 
been spread the cerate or substance employed, is placed over 
the wound, and held in position by turns of the roller or 
broad adhesive strips. 

The more important points in applying dressings, to which 
the attention of the student is directed, may be expressed in 
a few general rules : — 

I. The position of the patient should be that which is 
most comfortable and free from restraint. The bed or 
table should be placed so as to afford ample light and space 
to those enojaged in the dressinoj. 

II. Every article required in the dressing should be 
prepared and arranged before the wound is exposed. 
They should be placed in order, so that they can be easily 
and quickly reached. 

III. The removal of the old dressings, the cleansing of 
tlie wound, and the application of the new dressings should 
all be performed in such manner as to avoid giving unne- 
cessary pain to the patient. Every movement of the sur- 
geon and assistants should be made with care — rough 
handling of the patient or of the wound should not, under 
any circumstances, be permitted. If tlie removal and appli- 
cation of the dressings cause great pain, the patient should 
be placed under the influence of an anaesthetic agent. 

IV. The wound should be exposed for as short a time as 



SURGICAL DRESSINGS. 35 

possible. Renewal of the dressings, unless the discharge 
is excessive, is not usually required oftener than once m 
twenty-four hours. Frequent dressings disturb and expose 
the wound, and thus interfere with the process of repair. 

Y. The fingers should not be used in removing the dress- 
ings or foreign substances from the wound, lest disease 
should be thus conveyed from one to another patient, or the 
surgeon become infected by the discharges. 

YI. The hands of the surgeon and assistants should be 
carefully washed both before and after the dressing. 

YII. All of the instruments used should be kept scim- 
pidoiisly clean. 

THE ANTISEPTIC SYSTEM OF DRESSING WOUNDS. 

The System of Lister. — This is a system introduced by 
Sir Joseph Lister, who defines it as " the dealing with sur- 
gical cases in such a way as to prevent the introduction of 
putrefactive influences into wounds." 

The following articles are necessary in order to properly 
carry out the antiseptic method in surgical operations and 
dressings : — 

1. Two solutions of carbolic acid, 1 in 40 (twelve grains 
to the ounce), and 1 in 20 (twenty-four grains to the ounce), 
should be prepared, — the first for the protective and loose 
layer of gauze, the second for the spray, and in w^hich the 
sponges, instruments, and drainage tubes are immersed, and 
also which is used to wash the part and the hands of the 
surgeon and assistants. 

2. Steam Spray Apparatus. — This consists essentially ot 
a spirit lamp with a hollow wick, a boiler to contain w^ater, 
a bottle to hold the solution of carbolic acid (1 in 20), and a 



36 



SURGICAL DRESSINGS. 



spray-tube. An excellent and inexpensive apparatus has 
been devised by Dr. R. F. Weir, of New York (Fig. 19). 



Fig. 19. 




3. Antiseptic Gauze. — This is prepared as follows: — 
Coarse-meshed cotton cloth, known as dairy or cheese 
clotli, is heated above 212°, and then sprinkled with its 
own weight of a mixture of carbolic acid one part, common 
resin four parts, and paraffin four parts, the latter being 
melted together in a water-batli, and the acid then added 
by stirring. Pressure is then applied, so as to disseminate 
the liquid equally through the cloth. Old mosquito netting, 
which has been boiled in lye, can be used in place of the 
dairy cloth. In cases in which it is desirable to economize 
with regard to the use of the guaze, the larger and least 
soiled pieces can be washed and re-charged and used in 
future dressings as loose gauze. The expense of preparing 
the gauze can also be much reduced by the substitution of 



SURGICAL DRESSINGS. 37 

castor oil for the paraffin as practised by Von Briins, accord- 
injj to the followinij formula : — 



c 



Carbolic acid . . . . .1 part 

Resin 4 parts 

Castor oil 8 " 

Alcohol 20 " 

The resin is dissolved in the alcohol and then the castor 
oil and carbolic acid are added by stirring in well. The 
gauze is simply soaked in this solution and then hung up to 
dry ; in a few minutes it will be ready for use. Benzine 
may be used in the place of alcohol, still further reducing the 
cost of preparation. Its purpose is to absorb the fluids from 
the wound, and to prevent their decomposition. 

4. The Mackintosh — This is a material used in the 
manufacture of hats, and consists of thin cotton cloth with a 
layer of red vulcanized rubber on one side. Thin rubber 
cloth, oiled silk, or gutta percha tissue will be found proba- 
bly as effective. The material used should be free from 
holes. The Mackintosh is used to compel the secretions to 
permeate the whole dressing, thus being constantly in con- 
tact with the carbolic acid. It is placed between the seventh 
and eighth layers of the gauze. 

5. Rubber Tubings These are used for drainage, and 

vary in size from one-eighth to one-half of an inch. 
Numerous openings, each half the diameter of the tube, 
are made on the side. Red rubber tubes should be used as 
they contain no free sulphur. (Fig. 20 ) 

When introduced into a wound or cavity, the outer end 

of the tube should be cut flush with the surface of the skin, 

and should be secured in place by two threads of carbolized 

silk, fastened into the end and tied in a knot, which can be 

4 



38 



SURGICAL DRESSINGS. 



placed between the skin and dressings. In order to obtain 
greater security strips of gauze wet with carbolic lotion can 
be inserted between the loops. 

Fig. 20. 




The tubes should be kept constantly in a la^ge vessel con- 
taining 1 to 20 carbolic acid solution. Tubes which are 
to be returned should not be removed from the wound until 
the third day, by that time a channel in the lymph has been 
formed which permits of an easy reintroduction. Before re- 
turning, all drainage tubes should be washed with a 1 to 20 
lotion of carbolic acid. 

In the place of rubber tubes catgut threads and horse hair 
have been employed. The former were introduced as means 
of drainage by Mr. John Chiene, and are used as follows : 
a bundle of the finest catgut threads, fifteen to twenty in 
number, is tied at the middle by a single thread which is 
passed through the eye of a curved needle (Fig. 21). By 
means of this needle the bundle is fastened to the deepest part 



SURGICAL DRESSINGS. 



39 



of the wound and three or four smaller bundles, of five or six 
threads each, are formed which pass out of the wound at the 
angles and at intervals between tlie sutures. (Fig. 22.) 

Fiff. 21. 




The ends of the threads should be long in order to facilitate 
the capillary action. In five to six days these ends become 
detached and the portions within the wound disappear by ab- 
sorption. 

Drainage by bundles of horse hair has been employed 
with good results especially in joint wounds. The bundles 
are placed in such parts of the wound as may be requisite. 
The hairs can be removed one at a time, as the conditions 
of repair require ; they are not absorbable. 

Dr. Neuber, of Kiel, has employed decalcified bone tubes 
in place of rubber. They are made by drilling long bones 
and cutting holes in the sides, and possess the advantage of 



40 



SURGICAL DRESSINGS. 



being capable of undergoing absorption. Dr. MacEwen has 
substituted chicken bones, which are prepared by scraping 

Fig. 22. 




and immersing in a solution of hydrochloric acid 1 to 5 of 
water. When sufficiently softened the ends are cut off, the 
interior cleaned out, and they are re-immersed in the acid 
solution until they become quite pliable. Holes are cut out 
of the sides at proper intervals and they are placed in a solu- 
tion of carbolic acid and glycerine (one-to-ten). At the end 
of two weeks they may be used. Horse hair is passed 
through the tubes before introduction into the wound, which 
prevents collapse of the tube and also facilitates drainage by 
capillarity. 



SVllGICAL DRESSINGS. 41 

6. The Protective is a piece of oiled silk wliich is placed 
over the wound to protect it from the irritating effects of 
the carbolic acid in the antiseptic gauze. It is prepared by 
coating it with a thin layer of copal varnish, and then brush- 
ing over with a mixture of dextrine one part, starch two 
parts, and sixteen parts of the one-to-twenty carbolic acid 
solution. 

7. CarhoUzed Catgut Ligatures are made by putting cat- 
gut ligatures into a mixture of carbolic acid one part, dis- 
solved in one-tenth its weight of water, and then added to 
five parts of olive oil. A stronger article of catgut ligature 
may be obtained by immersing the ordinary catgut for forty- 
eight hours in a solution formed by dissolving one part of 
chromic acid in 4000 parts distilled water and adding 200 
parts of pure carbolic acid. It is then taken out and dried 
and put in the one-to-five carbolic oil. 

It is important to employ a convenient receptacle in which 
the catgut can be kept for use. Glass vessels or bottles con- 
taining carbolic oil one to five, and holding two or three glass 
reels upon which ligatures of different sizes are wound, with 
openings through the lid or with tubes passing through the 
stopper for the passage of the ends of the ligature, serve the 
purpose well. Sir Joseph Lister has devised a catgut holder 
— consisting of a reel placed within a German silver case — 
it can be carried in the ordinary pocket-case. 

8. CarhoUzed Silk Sutures are prepared by placing them 
in a mixture of melted wax nine parts and carbolic acid one 
part, and afterward drawing them through a folded cloth to 
render them smooth. They should be kept in closely stop- 
pered bottles. 

9. Sponges — These are carefully beaten, cleaned, and 
washed in lukewarm water, and kept in the one-to-twenty 

4* 



42 SURGICAL DRESSINGS. 

solution of carbolic acid. After use they are cleaned and 
returned to the solution. Sponges frequently become filled 
with fibrin during operations. In order to clean them they 
should be allowed to soak some hours in a solution of car- 
bonate of sodium — one-quarter pound to one gallon of water 
— during which time tlie fibrin is dissolved, and can be re- 
moved readily by repeated washings. They should be then 
placed in the one-to-twenty carbolic acid solution. 

An operation under the system is performed as follows : 
Three shallow basins (those which are oblong in shape are 
more convenient) should be at hand ; one containing the 
one-to-twenty solution to hold the instruments ; the second, 
containing the one-to-forty solution, for the sponges. The 
hands, and particularly the finger ends, of the surgeon and 
all of the assistants are to be washed in the tliird basin, con- 
taininoj a solution of the same strenorth. The bottle of the 
spray apparatus is filled with the one-to-twenty solution, 
and the apparatus set in operation. The surface is washed 
with the one-to-twenty solution, and the spray directed upon 
the part. The incision is made, the blood cleared away by 
the sponges, vessels ligatured with the catgut ligatures, 
which are cut off short ; drainage tubes introduced into the 
depths of the wound and brought out to the surface at the 
most dependent part and cut off short, and the wound closed 
with the carbolized silk sutures. If complete drainage can- 
not be effected through the wound, a counter opening should 
be made, and tlie drainage-tube introduced through it. A 
piece of the oiled silk protective, which lias been kept in 
one-to-forty solution, of a size to barely cover the edges, is 
now placed over the wound, then a piece of the gauze in 
one layer and wet in the one-to-forty carbolic lotion, and 
of such size as to largely overlap the protective. This consti- 



SURGICAL DRESSINGS. 



43 



tutes the ileep dressing (Fig. 23). The uneven surfaces must 
be then covered with loose gauze so as to fill up all depres- 



Fiff. 23. 




sions, and the outside gauze dressing, consisting of a piece of 
suitable size, folded in eight layers, with a piece of Mack- 
intosh with rubber side inwards, between the seventh and 
eight)], then applied. This dressing is held in position by 
a bandage, and an elastic bandage is applied around the 
edges of the dressing to keep them in contact with the sur- 
face of the body during movements of the patient. Safety 
pins are used to secure the elastic bandage to the edge of the 
dressing. 

Wet carbolized towels should be placed over the blankets 
covering the patient, or near at hand on the table upon 
which the instruments may be laid, and a towel, w^et in the 
one-to-forty lotion, should be placed conyepiently, so as to 



44 SURGICAL DRESSINGS. 

cover the wound, in case of failure of the spray apparatus, or 
to be thrown over a portion while operating in large wounds. 

If, .during the operation, the spray apparatus fails, the wet 
towel, called the guard, must be quickly applied over the 
wound, and kept there until the spray is again directed upon 
the part. The dressing is, as a rule, renewed in twenty- 
four hours, and this is done under the spray, the same pre- 
cautions being taken as in the first dressing. If the piece 
of oiled silk protective is unchanged in color, the wound is 
aseptic. If it shows dark-brownish spots, which are caused 
by the action of the liberated sulphur in the pus upon the 
lead in the oiled silk, the wound is septic, and should be 
washed out with the one-to-twenty solution, or with a solu- 
tion of chloride of zinc (forty grains to the ounce of water), 
one part of the solution of the chloride of zinc to three parts 
of water. 

In redressing, everything is renewed except the Mack- 
intosh, which can be washed off with the one-to-twenty 
solution, and reapplied. The extent of the discharge, the 
sensations of the patient, and the temperature elevation, 
are the guides which direct with regard to a renewal of the 
dressings. If the dressing has been successfully applied, the 
temperature should be normal or but little elevated. So 
long as everything is favorable the dressings need not be 
disturbed, though they should not be allowed to remain in 
place for more than a week. 

In cases of wounds not made by operation, as lacerated 
wounds, compound fractures, etc., a somewhat different plan 
of treatment is to be adopted, although the articles of dress- 
ing and their method of application are the same. The 
wound is to be treated as a septic wound, and is to be 
thoroughly washed out with a one-to-twenty carbolized solu- 



SURGICAL DRESSINGS. 45 

tion, or a solution of one part of carbolic acid to five parts 
of spirits of wine, and then dressed as before described. In 
cases of suppurating wounds, old ulcers, etc., they should be 
first swabbed out with a solution of chloride of zinc, forty 
orrains to the ounce, and then dressed with the usual anti- 
septic dressings. 

This plan of treatment has been modified recently in the 
use of boracic instead of the carbolic acid dressings. All 
recesses and sinuses should be freely opened up, and the un- 
healthy granulating surfaces thoroughly scraped by curettes 
which may be made of different shapes and sizes (Figs. 24 

Fig. 24. 



and 25), and th( n purified by washing out with solution 
of chloride of zinc, forty grains to the ounce of water, and 
the surrounding skin thoroughly cleansed by washing 
with the one-to-twenty carbolic lotion. Then the ulcer is 
covered, as in the former dressings, with a piece of pro- 
tective which has been dipped in a boracic acid solution, 
saturated solution in water — one part in thirty parts of cold 
water ; over this is applied a piece of boracic lint of suflficient 
size, secured in place by an ordinary bandage. In the place 
of the chloride of zinc solution iodoform has been recently 
used; it is powdered freely over the surface, and gives no 
pain, having rather an anoesthetic power. If putrefaction 
does not cease after one application of the zinc or iodoform, 
a second may be made. The dressings should be renewed 
on the second day, but after that an interval of three or 
four days may be allowed to elapse if the discharge is not 



46 



SURGICAL DRESSINGS. 



great. In changing the dressing the spray is not required. 
The boraeic lint may be made by soaking ordinary lint in a 



Fiff. 25. 







hot saturated solution of boracic acid, and contains about 
one-half of its weight of crystals of the acid, and its anti- 
septic qualities, therefore, last for some time. The borated 
cotton-wool is made in the same manner. Both the lint 
and lotion are tinted with litmus to distinguish them from 
carbolic preparations. The chloride of zinc solution can be 
used for the purpose of purifying ulcers, sinuses, etc., by 



SURGICAL DRESSINGS. 47 

waf^liing out witli a piece of lint, or by injection by means of 
a syringe, and, if necessary, for the deeper parts, a catheter. 
Care should be taken, to afford a free exit lest gangrene 
should result from retention of the fluid. 

Boracic, salicylic, or eucalyptus ointments may be used 
in superficial wounds especially, instead of the protective. 
These ointments are made according to the following for- 
mula : A basis of tioo parts of paraffine and one of vaseline 
is made. Boracic ointment is made by mixing one part of 
the acid and Jive parts of the basis. Salicylic ointment 
consists of one part of the acid and twenty-nine parts of the 
basis. Eucalyptus ointment is made in the proportion of 
one part by measure of the eucalyptus oil, and /bz/r parts by 
weight of the basis. Full strength and half strength pre- 
paration of these ointments can be made. 

Since the introduction of the antiseptic system of dressing 
wounds by Lister, a number of modifications of the plan, 
both as to the agents employed and the manner of applica- 
tion, has been suggested and carried into practice with more 
or less success. Owing to the irritating and poisonous pro- 
perties of carbolic acid and its claimed inferiority as a ger- 
micide, endeavors have been made to obtain a substitute. 
For this purpose the following agents have been employed : 

Salicylic Acid. — This was introduced by Prof. Thiersch, 
of Leipzig, and is used in the form of a solution, one part of 
the acid to three hundred parts of water, at the ordinary 
temperature. 

Salicylated Cotton-wool and SciUcylated Jute are em- 
ployed as dressings. Salicylated Cotton-wool is made of two 
strengths, 3 per cent, and 10 per cent. The first is made 
by immersing twelve pounds (5^ kilogrammes) of absorbent 



48 SURGICAL DRESSINGS. 

cotton-wool in a solution of six ounces (170 grammes) of 
salicylic acid, one gallon (3099^ grammes) of alcohol (sp. gr. 
0.830) and nine gallons (33 litres) of water at a temperature 
of 150° F. 

The second (10 per cent.) is made by immersing 22 
pounds (ten kilogrammes) of absorbent cotton-w'ool in a 
solution of 34 ounces (one kilogramme) of salicylic acid, 20 
gallons (10,000 grammes) of alcohol (sp. gr. 0.830) and 16 
gallons (60 litres) of water. 

Salicylated Jute, 3 per cent., is made by immersing 83^ 
ounces (2500 grammes) of jute which has been cleaned, in 
a solution of 2^ ounces (75 grammes) of salicylic acid, 16§ 
ounces (500 grammes) of glycerine, and 150 ounces (4500 
grammes) of water at 158-176° F.. (70-80° C). In this 
preparation the glycerine holds the salicylic acid in the jute. 

In the application of the dressings the solution used for 
the spray is the 1-300 salicylic acid. The instruments 
must be placed in solution of carbolic acid, owing to the 
oxidizing effect of the salicylic acid on the steel. A piece 
of perforated gutta-percha tissue, covered with a piece of 
gauze three fingers' breadth in thickness, is placed over the 
wound. Over this a layer, one finger's thickness, of the 10 
per cent, salicylated wool, and two fingers' tliickness of tlie 
3 per cent, wool is placed, and all is secured in place by a 
bandage. If no pain is complained of, the dressing remains 
in position for eight or ten days, when it is changed to re- 
move the drainage-tube; if any discharge appears through 
the dressing, fresh wool is applied outside. The second 
dressing is not disturbed until healing is completed. The 
protective and JNIackintosh are not required. 

Thymol. — This agent was introduced some years ago by 
Ranke of Halle as a substitute for carbolic acid. Its use lias 



SUK(UCAL DKESSINGS. 49 

been largely abandoned on acount of its very feeble antiseptic 
properties and of the objections made to its sweetish odor, 
which produced headache and attracted swarms of flies. 

Eucalyptus Oil. — Schulz of Bonn, Germany, has recently 
suggested the use of this oil as possessing valuable antiseptic 
qualities, and Sir Joseph Lister has made trial of its virtues 
in the treatment of wounds. Its odor is pleasant, it is non- 
poisonous, and unirritating. Preparations of gauze and 
ointment have been made and have been found satisfactory. 
A solution can be made, in varying proportions, with olive 
oil or dissolved in alcohol. 

Acetate of Alumina Quite recently the acetate of alu- 
mina has been suggested by Prof. Maas, of Freiburg, he 
claiming that with a 2.5 percent, solution he obtains aseptic 
results. A protective is^ applied over the wound and over 
this compresses soaked in the solution, the whole dressing 
being covered by an impermeable tissue. The dressings 
require to be removed at rare intervals. 

A ceto-tartr ate of Alumina has been introduced as an anti- 
septic by Kiimmel, of Hamburg. It is used in J to 3 per 
cent, solutions and mixed with charcoal, three parts of the 
salt to seven of baked cliarcoal. This form of dressing may 
remain undisturbed for one or two weeks. 

Iodine This agent has been long employed as a topical 

application. Mr. Bryant has used a solution of iodine and 
water in the proportion of twenty drops of the tincture to 
one ounce of water to wounds for the purpose of checking 
hemorrhagic oozing, and for purification of the surfaces. 

Iodoform contains ninety-six per cent, of iodine, and is a 

much more eligible preparation. As an antiseptic dressing 

its use was first recommended by Prof. Von Mosetig Moor- 

hof of Vienna. While it is quite soluble in ether and the 

5 



50 SURG1CAI> DRESSINGS. 

oils, less so in alcoliol and water, it is best used in the form 
of the powder and the iodoformized gauze. The ''absorbent 
iodoform gauze" is pi-epared by rubbing into the meshes 
roughly the powder of iodoform. The loose gauze is placed 
in a basin which has been washed out with carbolic lotion 
and freely sprinkled with iodoform powder, a pepper box 
being used for that purpose. The powder is worked in with 
the hands until the gauze is of a uniform yellow color. The 
excess is shaken out and the gauze, now ready for use, is 
put in sealed glass jars. It contains from 10 to 20 per cent, 
of iodoform. Adhesive iodoform gauze is made by soaking 
gauze in a solution of resin 100 parts, alcohol (95 per cent.) 
1200 parts, and glycerine 50 parts, and then dusting iodo- 
form upon the surface after it has been wrung out and parti- 
ally dried. This form contains nearly four times more of 
iodoform than the ordinary gauze. Iodoformized cotton- 
wool may be used, and is prepared by soaking in the follow- 
ing solution : Iodoform 50 parts, ether 250 parts, and 
alcohol 750 parts. It may be made extemporaneously by 
rubbing the powder into the substance and shaking so 
as to git rid of the excess. Owing to its slight solubility 
in water, iodoform is not adapted for the disinfection 
of sponges, instruments, etc., or for application to surfaces 
which have not been purified by other antiseptic agents, as 
carbolic acid, corrosive sublimate, etc. Over fresh or puri- 
fied wounds it may be gently powdered, the wound closed 
and dressed with several layers of the iodoformized gauze, 
this covered by gutta-percha tissue, and tlie whole secured 
in place by a bandage. In open wounds the surfaces are 
sprinkled over lightly, the cavity packed w^ith iodoform 
gauze and the dressing completed as in the fresh wound. 
Objections exist with regard to the use of iodoform as a 



SURGICAL DRKSSINGS. 51 

dressing on account of the odor and of the very decided 
toxic qualities it possesses. The disagreeable odor can be 
masked by the use of various agents, as Peruvian balsam, 
musk, the essential oils, as bergamot, clove, and peppermint, 
and the Tonka bean. In order to avoid producing toxic 
effects great caution should be excerised in its use ; it has 
been ascertained by Neuber from the experience he has 
gained that not more than forty to forty-five grains can be 
placed safely upon a fresh wound-surface, and this amount 
cannot be taken as the limit as the susceptibility varies in 
different cases. The symptoms of poisoning are headache, 
loss of appetite, wakefulness, the constant taste of iodoform, 
and, in the severer cases, mental derangement to the extent 
even of acute mania. The treatment consists in the prompt 
removal and discontinuance of the dressings, and the use of 
alcoholic stimulants. 

Naphthalui. — This agent is one of the products of coal tar, 
and was first used as a dressing by Dr. Fischer of Strassburg. 
It is employed in the form of powder and is applied in the 
same manner as iodoform. While its antiseptic power is 
less than iodoform, it possesses the advantage of being free 
from toxic properties, and can be substituted, therefore, for 
it. Gauze coverings may be impregnated with it. 

Subnitrate of Bismuth Finely-powdered subnitrate of 

Bismuth suspended in water so as to form an emulsion is 
advocated by Prof. Kocher of Berne as an efficient anti- 
septic wound-dressing. A one per cent, watery mixture is 
used for sprinkling over wound surfaces and spread over the 
line of sutures with a brush after closure of the wound in 
operations. Gauze which has been immersed in a ten per 
cent, mixture of bismuth and wrung out is applied, then a 
layer of cotton-wool covered by gum tissue, and over the 



52 STJUGICAL DRESSINGS. 

whole a bandage to secure the dressing in place. Toxic 
effects manifested, it is stated, by the symptoms of acute 
stomatitis, intestinal catarrh, and desquamative nephritis, 
have been produced by the use of strong mixtures which are 
now abandoned, and the excessive application of the powder 
to cavities. These conditions are transient, and subside 
after discontinuance of the dressings. The value of sub- 
nitrate of bismuth is impaired by reason of its want of con- 
trol over erysipelas. 

Permanganate of Potassium This agent has long been 

in use as a wound-disinfectant in the form of aqueous solutions 
of 5 to 20 parts to 100. Prolonged antiseptic effects can- 
not be accomplished by it, owing to the rapid decomposition 
which occurs when it is brought into contact with organic 
substances. 

Chloride of Zinc The chloride of zinc, as is well known, 

possesses powerful caustic properties, and it has taken part in 
antiseptic dressings usually in such strengths (40 grains to 
the ounce) as to secure purification of septic M'ounds. 
Dilute solutions, 1 to 500, are advised for washing out large 
suppurating cavities which are protected against the entrance 
in the future of septic agents by an external antiseptic 
dressing. Its action on the tissues interferes with union by 
the first intention. 

Terehene Tliis is a product of the oil of turpentine, and 

is used as a wound application by saturating sponges with it 
and placing them over the Avound. It is stated that Mr. 
Furneaux Jordan after amputations places one between the 
flaps and allows it to remain for several hours. 

Corrosive Sublimate. — Of all the substances introduced as 
wound dressings none seems to have met with more general 
favor than corrosive sublimate, possessing all the advantages 



SURGICAL DRESSINGS. 53 

of powerful germicidal properties, ease of application in 
many forms, and freedom from danger of producing toxic 
effects, in solutions of efficient antiseptic strengths. It was 
first used as a wound dressing by Kiimmell and Schede in 
the Hamburg General Hospital in 1881. It has been used 
in solutions varying in strength from 1 in 100 to 1 in 5000. 
It has been found that a solution of 1 in 1000 (7 J grains to 
the pint of water) is in all respects reliable as an antiseptic 
and free from danger, and therefore it has been adopted as 
the standard. The articles which are used in the corrosive 
sublimate dressing are prepared in a very simple manner. 
According to Dr. Weir, jute and moss are dipped into a 
solution of corrosive sublimate 1 part to 1000 of water and 
50 parts of glycerine. They are soaked in this solution 
from ten to twelve hours, then wrung out and allowed to dry 
to the extent permitted by the glycerine. The gauze and 
cotton-wool are treated in this way. Deprived of oily 
matters they are immersed in a solution composed of corro- 
sive sublimate 20 parts, water 4480 parts, glycerine 500 
parts. A slight aniline tint is given to the gauze to distin- 
guish it. It is desirable that these preparations should be 
freshly made, as often a slight change occurs owing to the 
conversion of the corrosive sublimate into calomel. Prof. 
S. AV. Gross finds that the addition of common salt to the 
solution prevents the change of the corrosive sublimate into 
calomel, and suggests the following formula : — 

Corrosive sublimate 1 part . . grs. T^. 

Common salt 5 parts . . . grs. 37|. 

Glycerine 10 parts .... 3J-gtts. vij. 

Water 1000 parts . . . . Oj. 

A simple test may be applied to the dressings by the ap- 
plication of a few drops of lime-water ; if this is followed by 

5* 



54 SURGICAL DRESSINGS. 

the formation of a yellow spot, corrosive sublimate is pre- 
sent ; if by a black spot, calomel has formed. 

Sublimated catgut is used both as ligatures and sutures, 
and is prepared by placing it for ten minutes in 1 to 100 
solution ; then into a 1 to 1000 for ten to fifteen hours, and 
afterwards it is wound on glass spools and kept in absolute 
alcohol, or it may be put in oil of juniper for twenty-four 
hours, and then in pure alcohol. Silk sutures are immersed 
for two hours in a 1 to 100 solution of corrosive sublimate, 
and kept for use in a 1 to 1000 solution. 

Drainage-tubes, either of rubber or decalcified bone, are 
used ; in order to prevent the two rapid absorption of the 
latter, they are kept in pure alcohol which hardens them. 

Sponges after being cleaned are kept in the 1 to 1000 so- 
lution of corrosive sublimate ; preferably in that to which 
the salt has been added, as suggested by Dr. Gross. 

Neither protective nor impermeable outer covering are 
required in the dressing. 

Before an operation the surfaces about the points of in- 
cision are scrubbed with soapsuds, and afterwards painted 
over with an iodoform solution or washed with a solution of 
turpentine and alcohol, two ounces to the pint, in order to 
dissolve all greasy matters and to purify the parts. The 
hands and nails of the surgeon and assistants are publicly and 
thoroughly washed and disinfected. The instruments, owing 
to the corroding effect of the corrosive sublimate upon the 
metal, must be immersed in the 1 to 20 solution of carbolic 
acid. 

If the spray is used, it must be formed from the carbolic 
acid solution. 

In the dressing, bandages, one and a half to two inches 
in width, made from the sublimated gauze or crinoline, are 
employed. 



SURGICAL DRKSSINGS. 55 

During the operation, without the spray, the solution (1 
to 1000) is allowed to run continuously over the incision, 
the patient being protected by a rubber blanket, which is 
arranged so as to expose only the part operated upon. In 
order to avoid any danger as to the toxic effects of the solu- 
tion, Tliiersch has suggested the boro-salicylic solution con- 
sisting of boracic or boric acid 6 parts, salicylic acid 1 part, 
and water 500 parts ; this is employed during the operation, 
the wound being finally washed with the corrosive sublimate 
solution. 

After the vessels have been ligatured, and hemorrhage has 
ceased, drainage-tubes of rubber or bone are put in place, 
the wound is cleaned and then closed with catgut sutures, 
using the continued instead of the interrupted suture for that 
purpose. The interior of the wound is cleaned by injecting 
the sublimate solution through the drainage-tubes, and the 
surfaces compressed by several sponges until a piece of sub- 
limated gauze can be applied over the centre of the wound. 
The pressure being maintained, several layers of the gauze, 
not too wet, are applied and secured in place by turns of a 
sublimated gauze bandage. Over the dressings, carried thus 
far, the absorbent materials are placed, being retained in 
bags of suitable size and shape. These are from one to two 
inches in thickness, and may contain peat, wood-wool, or 
any other substance which may be selected. Those of smaller 
size are packed about the wound and then covered by a large 
one, and over all a crinoline bandage wet with the subli- 
mated solution is applied. If the discharge appears upon 
the surface of the dressing, the parts can be douched with 
the sublimated solution, and cotton-wool or gauze applied 
over the part. The dressings may remain in place for several 
days if no elevation of temperature occurs. In most instances 



56 SURGICAL DRESSINGS. 

but one change of dressing is required until healing has taken 
place. 

A dressing, according to this method, may be made extem- 
poraneously by dissolving seven and a half grains of corrosive 
sublimate in a pint of warm water, dipping ordinary absorbent 
cotton into the solution, wringing it as dry as possible, and 
securing it in place over the wound bj^ a bandage wet in the 
same solution. Drainage can be effected by the introduction 
of the perforated rubber tubing. This dressing may remain 
until one more elaborate is prepared if deemed necessary. 

Modifications of the Antiseptic Method Various modifi- 
cations of the antiseptic method of wound-treatment liave, 
from time to time, been introduced. 

Trendelenburg has published the results obtained by him 
in operations and treatment of wounds without the use of the 
spray. During the operation he allowed the carbolic acid 
solution to run over the wound, and, while filled with the 
solution, it was closed. At the time of changing the dress- 
ing, the same precautions were taken. 

The late Mr. Callender, of St. Bartholomew's Hospital, 
London, employed carbolic acid and olive oil, one to 
twelve, having first brushed over the cut surfaces a solu- 
tion of chloride of zinc, forty grains to the ounce of water, 
or washed the wound with the one in twenty solution of car- 
bolic acid. He then covered the wound with lint saturated 
in this solution, and surrounded the part with cotton-wool. 
Hemorrhage was controlled by torsion of the vessels. 

Methods of wound-treatment not strictly antiseptic: — 

Guerin^s Cotton-wool Dressing. — Originally this method, 
introduced by Alphonse Guerin, consisted in the application 
of large masses of the ordinary cotton-wool which were 
firmly secured in place by a bandage, the wound having 



SURGICAL DRKSSINGS. 57 

been washed out with tepid water. At present the wound 
is washed out with a carbolic acid solution, and the deep 
layers of the cotton-wool are wet with the carbolic lotion. 
Between the layers of cotton the powder of camphor is 
sprinkled, layer after layer of cotton is applied and very 
firmly secured wnth the bandage, so as to make uniform 
compression. As much as five pounds of cotton have been 
sometimes applied. Formerly no sutures were employed, 
but recently, with a view to obtain primary union, they 
have been introduced. The precautions to be taken in ap- 
plying this dressing are important: 1. The dressing must 
not be applied or renewed in the ward, but in a room some 
distance from it. 2. The cotton-wool should not be opened 
in the ward, owing to danger of contamination from the air. 

The dressing is allowed to remain undisturbed from two 
to three weeks; if the discharge comes through, the dress 
ing may be washed with carbolic acid solution, and a fresh 
layer of cotton applied. The object sought to be accom- 
plished by this dressing is to exclude, by filtration, septic 
agents, and also to maintain elastic compression and constant 
temperature. It is also claimed that it secures the suppres- 
sion of pain, absence of traumatic fever, and diminution of 
suppuration. 

The dressing has been modified by M. Oilier, who soaked 
the deep layers of the cotton-wool in carbolic oil. 

Alcohol has been employed as a dressing with good results. 
The method of Mr. Jonathan Hutchinson is as follows : 
Hemorrhage having been controlled chiefly by torsion, the 
wound is washed out with pure alcohol, drainage-tubes in- 
serted, and sutures introduced. Over the wound, thin com- 
presses of lint, soaked in a solution of absolute alcohol six 
parts, liquor plumbi one- half of a part, and distilled water 



58 SURGICAL DRESSINGS. 

sixteen parts, are applied and are kept constantly moist pre- 
ferably by a drop irrigator. The compresses are clianged 
daily. The alcohol acts as an antiseptic, and primary union 
is generally obtained. 

Tile Open ^Jethod Tliis method was first employed by 

Dps. Bartscher and Yezin. wlio practised it in the following 
manner : after the cessation of hemorrhage, the wound is 
cleansed by washing out with cold water, and, in case of an 
amputation, the stump is placed on a soft pillow and over it 
a piece of gauze or linen to keep out the flies. On the next 
day a clean pillow is placed beneath the limb without any 
cleansing of the wound being made. No sutures are em- 
ployed ; by this method primary union is not accomplished. 
Modifications of the method have, from time to time, been 
introduced. In some the edges of the wound are brought 
together by sutures or strips of plaster, and antiseptic solu- 
tions are used to clt-anse tlie parts. The late Dr. Wood, of 
New York, employed this met hod in a number of cases, 
modifying it, however, by tlie free use of carbolic acid and 
devoting great attention to tliorough cleanliness. 

Surgical Dressing Cases Cases, of ditferent sizes, con- 
taining all of the agents employed as wound dressings, are 
to be found in the stores of the instrument makers. Thus 
provided, the surgeon is enabled to make the primary dress- 
ing complete in all wounds the treatment of which he is 
called upon to conduct. 

In the treatment of wounds the great object to be attained 
is to secure if possible primary union, if this is not possible 
then to employ such means as will facilitate repair with as 
little delay as possible and with the least drain upon the 
vital power of the patient. 

Certain points of great importance are involved in the 



SURGICAL DRESSINGS. 



59 



treatment of all avouikIs, and should always claim careful 
attention. 

1st. Accurate coaptation of the wounded surfaces should, 
if possible, be always secured. This is accomplished by 
means of sutures which may be introduced, superficially for 
the purpose of coaptating the superficial tissues or deeply for 
the approximation of the deeper tissues ; these sutures have 
been designated respectively as sutures of coaptation and 

Fis. 26. 




sutures of approximation. There are also other sutures 
called sutures of relaxation, which are introduced some dis- 
tance from the margins of the wound for the purpose of re- 
laxing the tissues near the wound and thus preventing 
tension of the sutures of approximation. (Fig. 27.) The 
perfect coaptation of wounded surfaces prevents the accumula- 
tion of wound fluids and thus contributes to rapid healing. 
In securing it, however, great care should be observed that 
it is not accomplished at the expense of producing undue 
tension, which I'eacting upon the wounded tissues provokes 
iiTitation and induces conditions which interfere with and 
greatly retard the reparative process. If tension occurs 
during the progress of the healing process, it should be re- 
lieved by division of the sutures and the employment of 
such other means as may be found necessary. 



60 



SURGICAL DRESSINGS. 



Perfect Drainage. — The free escape of all fluids from a 
wound is essential to prompt repair and to the good condi- 

Fig. 27. 




Fiff. 28. 




tion of the wound. This is accomplished by means of 
tubes or other means which conduct the fluids from the 



SURGICAL DRESSINGS. 61 

wountls SO that they be washed away or may be rendered 
innocuous by agents incorporated in the dressings. The 
proper introduction of drainage tubes is important in order 
that the deeper parts of the wound should be drained and 
accumulations of fluids prevented. It can be understood 
readily in what manner the collection of fluids between 
wound surfaces interferes with repair. The fluids may act 
either mechanically by separating the surfaces or chemically 
by the septic influences exerted by them. 

Cleanliness. — In its fullest extent this term, as it relates 
to wound-treatment, includes cleanliness in the wound, or 
the parts about the wound, of all substances and instru- 
ments coming in contact with it and of the hands of those 
who, in any way, have anything to do with it. In wounds 
in which the surfaces are brought into contact, as after ampu- 
tations, excisions of tumors, etc., it is essential that the sur- 
faces should be thoroughly cleansed before approximation, so 
as to remove all blood-clots or shreds of tissue. In wounds 
which are treated aseptically the blood clots which may re- 
main disappear by a process called organization, young cells 
developing in them, and new tissue being thus formed, the 
blood clots affording the pabulum for the cells. The cleans- 
ing of wound surfaces which are in contact may be effected 
by injecting tepid water or warm antiseptic solutions through 
the drainage tubes which have been introduced. This 
should be done at the time of the first dressing, and also at 
the redressings. Open wounds may be washed by injections 
with the syringe ; for this purpose the fountain syringe is 
preferable, as a larger column of water can be obtained from 
it, and also the fluid is tlirown with less force from it upon 
the surfaces. In the absence of a fountain syringe, the nasal 
douche bottle can be used. A gallon tin measure can be 
6 



62 SUEGICAL drp:ssings. 

readily adapted by the tinsmith to the purpose of a wound 
douche. 

Cleanliness about the wound is effected by scrubbing the 
parts with soapsuds for some distance in all directions 
about the intended site of an operation, and afterward wash- 
ing w^ith an antiseptic lotion. In the redressings these sur- 
faces are kept clean by w^ashing carefully Avith the antiseptic 
solution, usually carbolic acid solution one-in-twenty. 

Cleanliness with regard to the dressings, sponges, and 
instruments is of paramount importance in preventing the 
entrance into the wound of septic agents. The general in- 
troduction of antiseptic methods permits of the employment 
of chemically clean dressings at slight cost and of processes 
by which sponges and instruments may be kept clean. With 
our present knowledge of wound-treatment no surgeon can 
be excused for want of care in this respect. Cleanliness of 
the hands of the surgeon and assistants is important, and 
thorough washing should be practised before operations or 
redressings. Especial attention should be given to the folds 
of the skin about the finger nails and to the removal of dirt 
beneath the nails. The one-to-forty solution of carbolid acid 
is of sufficient strength to render the surfaces free from septic 
matter. 

Rest. — Perfect rest of a wounded part is essential to 
prompt repair. This may be accomplished by means of 
position and the use of bandages and splints. 

Position In all cases, that position should be selected 

which affords the most comfort to the patient and promotes 
the free escape of fluids from the wound. In injuries of the 
lower extremity it is desirable to elevate the limb either in 
a fixed apparatus or in a swing. When the limb is swung 
the parts are not disturbed by movements of the patient, 



SURGICAL DRESSINGS. 63 

and in this way great comfort is obtained as well as freedom 
from pain. In the treatment of wounds of both extremities 
elevation of the limb should be secured so as to maintain 
the free circulation of the blood through the part. 

Bandages By means of bandages equable compression 

may be made which will control muscular spasm and afford 
support to the bloodvessels. They should be applied from 
the distal extremity, and should be carried over the wound 
to some distance above it. Great care should be exercised 
in order to avoid making undue pressure. Sufficient trac- 
tion should be made to give comfortable support to the parts 
if it is carried beyond that point harm may be done. 

Splints — The use of splints is important in obtaining rest 
of a wounded part. Immobilization of the entire limb may 
be obtained by the employment of the plaster dressings. In 
the treatment of injuries of the joints fixation of the limb is 
very desirable. In applying splints care should be taken to 
protect the surfaces by covering them with cotton-wool or 
some soft material which w|ll adapt itself to the inequalities 
of the part. Splints should be made of light material which 
can be moulded to the part. 

In the treatment of wounds the surgeon should always 
bear in mind the great importance of maintaining the 
patient in the most favorable hygienic conditions possible to 
be attained, and of giving attention to the state of the general 
system. The relation which the condition of a wound may 
have to the constitutional state of the patient should not be 
overlooked, otiierwise the healing process may be seriously 
interfered with, despite the most perfect dressings. As per- 
fect ventilation as is possible of the apartment in which the 
patient is placed should be secured, in order not only that 
a full supply of fresh air should be admitted, but also that 



64 SURGICAL DEESSINGS. 

the air which is charged with the exhalations from the body 
and with other contaminations should escape. 

While it is hoped that pus will not form under the anti- 
septic method of dressings, yet it is not claimed that it will 
not occur. In such cases the " antiseptic suppuration/' as 
it is called, is said to be " due to the direct chemical stimulus 
of the antiseptic." 



PART 11. 

BANDAGING. 



Bandaging is tlie art of applying bandages. Bandages 
are substances which are employed in the treatment of sur- 
gical affections, and consist of the simple and the compound. 
They may be made from various materials, such as muslin, 
flannel, etc. For general use the material best adapted is 
unbleached muslin; that which is firm, smooth, soft, and 
closely woven should be selected. 

THE SIMPLE BANDAGE OR ROLLER. 

This may be from one to four inches in width, and from 
six to twelve yards in length. The ordinary roller used in 
practice is six to eight yards long, and two to two and a half 
inches wide. In preparing the roller a piece of muslin, six 
to twelve yards in length and one yard in width, should be 
soaked in water for some time in order to cause shrinkage, 
then dried, and smoothly ironed. The selvage is removed, 
the free edge divided by the scissors at the points marking 
the widths of the bandages, and the strips torn rapidly, so 
as to avoid too much unravelling. 

In order to apply the bandage it should be formed into 
rollers or cylinders : this can be done by a machine (Fig. 
29) or by the hand. It is quite desirable that the student 

6* 



66 



BANDAGING. 



should learn to roll the bandage firmly by the hand, as the 
machine is not always convenient, and, besides, constant 



Fig. 29. 




handling of the bandage gives him better knowledge and 
control of it. The strips can be conveniently made into 
rollers in the following manner: Having arranged a strip in 
regular folds, a graduated compress is formed at one extrem- 
ity and turned over firmly upon the thigh and rolled a fe\y 
times until a cylinder is formed of such size as to be readily 
grasped by the hand ; then it is placed between the thumb 
and index and middle fingers of the left hand, the body of 
the bandage being held by the thumb and extended index 
finger of the right hand, while the remaining fingers grasp 
the cylinder. The cylinder thus held is made to revolve 
upon its axis by the left hand, while the right revolves par- 



BANDAGING. 



G7 




tially around the roller itself, Fig. 30. 

these movements soon complet- 
ing its formation. In forming 
the roller in this manner, the 
cylinder may be held in either 
the right or left hand, as is 
most convenient (Fig. 30). 
The roller should be firmly and 
compactly formed, so that the 
central portion or axis cannot 
be pushed out readily. Prac- 
tice will enable the student to 

accomplish the formation rapidly and firmly. After forming 
the roller it should be firmly grasped and all loose threads 
removed, as these interfere with 
its proper application. 

Rollers are of two kinds, Sin- 
gle-headed and Double-headed. 
The single-headed roller consists 
of a body or central part, an ini- 
tial and a terminal end, and an 
external *nd internal surface 
(Fig. 31). The double-headed 
roller has the same parts as the 
single-headed, both ends being 

formed into rollers (Fig. 32). The dimensions of the roller 
for the different parts of the body vary. 

For the Head — Five yards long and two inches wide. 

For the Body — Twelve yards long and four inches wide. 

For the Extremities — Eight yards long and two to 
three inches wide. 



Fig. 31. 




68 



BANDAGING. 



For the Hand — From five to eight yards long and one 
inch wide. 

The application of the roller should begin by placing the 
external surface of the initial end in contact with the part, 
securing it in position by a circular turn, and the cylinder 
should be held firmly in the palm of the hand. When the 
application is completed, the terminal end should be fastened 
by folding in the edge and introducing a pin transversely or 
horizontally as may be most convenient, the head being 
directed upward or outward (Figs. 33, 34), care being taken 



Fig. 33. 



Fig. 34. 





to cover the point. Pins should be introduced at the points 
where turns of a roller cross one another, so as to hold them 
in place. In applying a bandage to an extremity, it should 
begin at the distal part, in order to make equable pressure 
upon the bloodvessels. 

If a wet bandage is to be applied, it should be soaked in 
the lotion before application, otherwise, undue contraction 
will ensue if made wet when it is on the limb. 

The amount of traction to be used in the application of a 
bandage is a matter of the utmost importance, and should 



RANDAGINCr. 



69 



I 



be very carefully considered 
by the student; practice 
alone will enable him to 
acquire a proper knowledge 
upon this point. A band- 
age too tightly applied may 
do great harm, even to the 
production of gangrene 
(Fig. 35), the loss of a 
limb, and possibly the loss 
of life. The sensations of 
the patient and the condi- 
tion of the circulation in 
the limb, as shown at the 
distal points, are the best 
guides. These should be 
carefully noted a short time 
after the application of the 
bandage. If the patient 
complains of pain and 
numbness in the limb, and 
if the temperature of the 
partis lowered and the skin 
gives evidence of retarded 
circulation, then the band- 
age should be immediately 
removed. With regard to 
the tension the patient 
should always be consulted, 
and inspections at short in- 
tervals should be made. 
In applying the bandage 



Fig. 35. 




Gangrene from tight bandaging. 



70 BANDAGING. 

to the head or trunk, the student should stand at the side of 
the patient, not in front of or behind, and in making the 
various turns of the roller he should not walk around the 
patient but maintain a fixed position. In conveying the 
turns about the part, the bandage should be unrolled with 
an even and steady movement, not by short jerks. In re- 
moving the bandage from a part, each turn should be care- 
fully taken off and folded in the hand. 

Bandages are designated as the Circular, Oblique, 
Spiral, Spiral-reverse, Figure-of-8, Spica, and Re- 
current, according to the direction they take in applica- 
tion. 

The Circular bandage consists of circular turns about the 
part. 

The Oblique bandage covers the part by very oblique 
turns (Fig. 36). 

Fiff. 36. 




The Spiral bandage is applied by making spiral turns, 
each succeeding turn covering one-half of the preceding 
(Fig. 37). The reverse turn in this bandage is made in 
order that the bandage may adapt' itself equably and with 
more firmness to the part. In making it, the limb should 
be grasped by the left hand, so as to retain the preceding 
turn by the thumb and fingers; the roller, with not more 



BANDAGING. 



71 



than three inches unrolled, should be held above the part, 
the hand being in a state of supination. The unrolled por- 

Fiff. 37. 




tion of the bandage being kept perfectly lax, the right hand, 
holding the roller, should be turned from supination into 



Fis. 38. 




pronation (Fig. 38), making in this movement a short turn, 
and passing the roller under the limb into the left hand. 



72 BANDAGING. 

The position of the roller in the hand should not be changed, 
nor should traction be made until the limb is passed. 

The reverse turns will be in a line, if care is taken to keep 
the spaces between the successive turns of the bandage equi- 
distant; they should not be made over a joint or a subcuta- 
neous bone, owing to the increased pressure they exert. 

In the Figure-of-% bandage the turns cross each other so 
as to resemble the figure after which it is named. 

The Spica bandage is so named from its resemblance to 
the arrangement of the leaves of an ear of corn. 

The Recurrent Bandage In this the turns return suc- 
cessively to the point of origin, so as to form a covering for 
a part. 

The simple bandage consists of the Roller, either single 
or double headed, and is applied to various parts of the body. 

BANDAGES OF THE HEAD. 

Length of roller five yards, width two inches. 

1. Circular bandage of the forehead. 

2. Circular bandage of the eyes. 

3. Crossed bandage of one or both eyes. 

4. Crossed bandage of the angle of the jaw. 

5. Knotted bandage of the head. 

6. Recurrent bandage of the head, with single or double- 
headed roller. 

7. Gibson's bandage for the body of the lower jaw. 

8. Rhea Barton's bandage for the body of the lower jaw. 

1. Circular Bandage of the Forehead. 

Origin — Side of the head. 

Course— ThvQQ or four turns encircling the vault of the 
cranium. 



BANDAGlXCr. 



73 



Termination — Side of the head o})posite to the point of 
origin. 

Use — To make pressure or retain dressings to the head. 

2. Circular Bandage of the Eyes. 
Origin — Temporal region. 

Course — Three or four turns over tlie eyes and around the 
head. 

Termination — Temporal region, opposite to the point of 
origin. 

Use — To retain dressings to the eyes. 

3. Crossed Bandage of the Eyes. 
Origin — Side of the head. 



Fi-. 39. 



Fig. 40. 





Course — Two circular turns around the head, in a direc- 
tion from right to left to cover the right eye, from left to 
7 



74 BANDAGING. 

right to cover the left eye, thence to the nape of the neck, 
adapting the bandage to the surface by a reverse turn, if 
necessary, under the ear, over the eye, across the root of the 
nose to the side of the head, on a level with the parietal 
eminence, then circular turn around the head, making two 
or three turns in this manner alternately, and covering two- 
thirds of each preceding turn. 

Termination — Circular turn around the head. 

Use — To retain dressings to the eye (Fig. 39). 

To cover in both eyes, after the first turn over the eye 
has been made, the bandage should pass around the head 
and then down across the forehead, the root of the nose, over 
the other eye, under the ear, to the occiput and side of the 
head, thence around the head to the nape of the neck, and 
pass in the same direction as in the first turn. Applying 
these turns alternately, both eyes will be covered. 

Use — To retain dressings to both eyes (Fig. 40). 

4. Crossed Bandage of the Angle of the JaTV. 

Roller and compress. 

Origin — Side of the head. 

Course — Two circular turns around the head, in a direc- 
tion from right to left to cover left angle, and left to right 
to cover right angle, to the nape of the neck, making a 
reverse turn, if necessary, behind the ear, under the jaw, 
over the angle of the jaw, up in front of the ear, over the 
vertex obliquely, down behind the ear of the side opposite, 
under the jaw and repeat the turns, advancing from the 
angle of the jaw to the corner of the mouth. 

Termination — By a reverse turn on the side of the head 
opposite to the injured side, and making two circular turns 
from before backward around the head. 



BANDAGING. 

Fi-. 41. 



75 




Use — To support parts in the treatment of fracture of the 
angle of the jaw (Fig. 41). 

5. Knotted Bandage of the Head. Double-headed 
roller and compress. 

Origin — Body of the bandage over the compress covering 
the wound in the artery. 

Course — Carry both heads of the roller around the head 
in opposite directions, passing at the temporal region of the 
opposite side and returning to point of origin. Change the 
direction by making a half turn or twist over the compress, 
carrying the heads of the roller in opposite directions over 
the vertex and under the chin to the temple of the opposite 
side, passing and returning to point of origin, where a second 
turn or twist should be made and the heads of the roller con- 



76 



BANDAGING. 



ducted as in first turn, placing tlie knots behind each other 
in order. Continue these turns until three or four knots are 
formed. 

Termination — Circular turns around the liead, covering 
the knots. 

Use — To make compression in wound of the temporal 
artery (Fig. 42). 

Note This bandage, being applied with great firmness, 

makes great pressure upon the parts, and should be watched 
carefully in order to prevent injury. 



Fig. 42. 



Fis-. 43. 





6. Recurrent Bandage of the Head. Single- 
headed roller. 

Origin — Side of the head. 

Course — Two circular turns around the head to the middle 
of the forehead, then reversing the bandage and carrying it 
from before backward to the middle of the occiput, making 



lANDAGING. 



77 



a reverse turn and returning to the forehead, covering one- 
half of the preceding turn and continuing recurrent turns on 
alternate sides, covering one-half of each preceding turn, 
until the vertex is covered. 

Termination — By a reverse turn and then circular turns 
around the head to secure recurrent turns (Fig. 43). 

Recurrent Bandage of the Head. Double-headed 
roller. 

Origin — Body of the bandage over the middle of the fore- 
head. 

Course — The heads of the roller are to be carried in oppo- 
site directions around the vertex to the occiput, passing and 

Fi-. 44. 




returning to the point of origin ; the recurrent turns are to 
be made by the head of the roller held in the right hand, 



78 BANDAGING. 

each turn being secured by circular turns made bj the head 
of the roller held in the left hand (Fig. 44) ; continue these 
turns until the vertex is covered. 

Termination — Circular turn around the head. 

Use — Both bandages are used to retain dressings to the 
head. 

7. Gibson's Bandage for the Body of the Lower 
Jaw. 

Origin — Temporal region. 

Course — Down in front of the ear, under the chin, up in 
front of the ear of opposite side, over the middle of the ver- 
tex to the point of origin, making two turns ; then reverse 
the bandage from before hachiuard, making two circular 
turns around the head to the point of origin; thence to the 
nape of the neck, making reverse turn if necessary, carrying 
under the ear, in front of the chin, and back to nape of the 
neck. Repeat this turn, make a reverse turn and go to side 
of the head, and around the head by two turns to the middle 
of the occiput ; make a reverse turn and carry bandage over 
the vertex to forehead (Fig. 45). 

Termination — Either by circular turns around the head 
or by turn from occiput to forehead. 

Use — To support parts in treatment of fracture of the body 
of the lower jaw. 

8. Rhea Barton's Bandage. 

Origin — Beneath the occi[)ital protuberance. 

Course — Obliquely upward over the parietal eminence, 
across the junction of the sagittal and coronal sutures, down 
in front of the ear, under the chin, up in front of the ear of 
the opposite side, across the junction of tlie sagittal and 



BANDAGING. 



79 



coronal sutures, over the parietal eminence to the point of 
origin; thence obliquely downward and forward over the 



Fiff. 45. 



Fig. 46. 





angle of the jaw, in front of the chin, over the angle of the 
jaw of the opposite side, obliquely upward and backward to 
the point of origin. Continue these turns until the bandage 
is exhausted (Fig. 46). 

Termination — Occipital region, or by a turn around the 
head. 

Use — To support the parts in treatment of fracture of the 
body of the lower jaw. 



BANDAGES OF THE TRUNK. 

1. Circular bandage of the neck. 

2. Figure-of-8 bandage of the neck and axilla. 

3. Anterior figure-of-8 bandage of the chest. 

4. Posterior figure-of-8 bandage of the chest. 

5. Crossed bandage of one or both breasts. 



80 BANDAGING. 

6. Spica bandage of the shoulder. 

7. Spiral bandage of the chest. 

8. Circular bandage of the abdomen. 

9. Spiral bandage of the abdomen. 

10. Spica bandage of one or both groins. 

11. Spiral reverse bandage of the penis. 

1. Circular Bandage of the Neck. Length of 
roller, two yards ; width, two inches. 

Origin — Side of the neck. 

Course — Three or four circular turns around the neck. 

Termination — Side of the neck. 

Use — To retain dressings to the neck. 

2. Figure-of-8 Bandage of the Neck and Ax- 
illa. Length of roller, five yards; width, two inches. 

Origin — Side of the neck. 

Course — Two circular turns around the neck ; thence over 
the point of the shoulder, backward and downward to the 
axilla, under the axilla, up in front over the shoulder to the 
point of origin, repeating these turns two or three times. 

Termination — Circular turn around the neck. 

Use — To retain dressings over the shoulder or in the axilla 
(Fig. 47). 

3. Anterior Figure-of-8 Bandage of the Chest. 

Length of roller, seven yards 4 width, two and one-half 
inches. 

Origin — Axilla of either side. 

Course — Two circular turns around the chest to the point 
of origin, thence obliquely upward across the chest to the 
point of the shoulder, over the shoulder backward and down- 
ward to the border of the axilla, under the axilla obliquely 



BANDAGING, 



81 



upward, across the chest to the opposite shoulder, over the 
shoulder, backward and downward to the border of the axilla, 

Fi-. 47. 




under the axilla, repeating these turns three or four times 
(Fig. 48). 

Termination — By circular turns around the chest. 

Use — To draw the shoulder forward, and to retain dress- 
ings on the anterior surface of the chest. 



82 



BANDAGING. 

•Fig. 48. 




4. Posterior Figure-of-8 Bandage of the Chest. 

Tliis bandage is applied in the same manner as that just de- 




scribed, the turns being carried over the posterior instead of 
the anterior surface of tlie chest (Fig. 49). 



BANDAGING. 



83 



Use — To draw tlie shoulders back in the treatment of frac- 
ture of the chivicle, or to retain dressings on the posterior 
surface of the chest. 

5. Crossed Bandage of one or both Breasts. 

Length of roller, eight yards ; width, two and one-half 
inches. 

Origin — Axilla of the affected side. 

Coarse — Two circular turns under the breasts, around the 
chest to the point of origin, thence obliquely upward under 
the affected breast, across the front of the chest to the shoul- 
der, over the shoulder, obliquely downward across the back 

Fig. 50. 




of the chest to the point of origin; then, by a circular turn, 
under the breast, around the chest to the point of origin ; 
continue these turns alternately, gradually advancing forward 



84 ■ BANDAGING. 

in the oblique turns, and upward in the circular turns until 
the breast is fully supported (Fig. 50). 

Termination — Circular turns around the chest. 

Bandage for both Breasts. Length of roller, twelve 
yards ; width, two and one-half inches. 

This bandage is applied in the same manner as that just 
described, with the addition of oblique turns, supporting the 
other breast, which begin when the bandage, in the second 
circular turn, the first oblique turn having been made, has 
reached the opposite axilla ; then pass across the back of the 
chest over the shoulder down obliquely across tlie front of 

Fig. 51. 




the chest under the breast to the point of origin. These 
turns are continued, the circular and oblique turns alternat- 
ing, until both breasts are supported (Fig. 51). 

Use — These bandages are used to support the breasts in 
excessive lactation, or in abscess. 



BANDAGING. 



85 



6. Spiea Bandage of the Shoulder. Length of 
roller, eiglit yards; width, two and one-half inches. 

Origin — Arm of the injured side. 

Course — Circular and spiral reverse turns to the point of 
the shoulder, over the shoulder, obliquely downward across 
the front of the chest, for the right shoulder, and the back 
of the chest for the left shoulder, to the axilla of the sound 
side, under the axilla, obliquely upward across the front or 
back of the chest to the point of the shoulder, down in front 
or behind to the border of the axilla, under the axilla to the 
point of the shoulder, covering one-half of the preceding 
turn, thence to the axilla of the sound side. Continue these 
turns, covering one-half of each preceding turn, until the 
shoulder is covered (Fig. 52). 




Termination — Circular turns around the chest. 
Use — To retain the head of the humerus in place after 
dislocation has been reduced. 

8 



86 



BANDAGING. 



7. Spiral Bandage of the Chest. Length of the 
roller, ten yards ; width, three to four inches. 

Origin — Circular turns around the waist. 

Course — By spiral turns around the chest, ascending to 
the axilla, covering one-half of each preceding turn. 

Termination — Circular turns around the upper part of the 
chest. 

Use — To make compression in fracture of the sternum or 
ribs, and to retain dressings (Fig. 53). 

Fiff. 53. 




8. Circular Bandage of the Abdomen. Length 
of the bandage, from one-and-a-half to two yards ; width, 
from ten to twelve inches. 

Origin — Over the crest of the ilium. 
Course — Circular turn around the abdomen. 
Termination — Over the crest of the ilium. 
Use — To support the abdominal walls. 

9. Spiral Bandage of the Abdomen. Length of 
the roller, ten to twelve yards ; width, three to four inches. 



BANDAGING. 



87 



Origin — Around the waist, or over the crest of the ilium. 

Course — Spiral turns from above downward, or from 
below upward. 

Termination — By circular turns around the pelvis or 
around the waist, according to the course taken. 

Use — To make compression of the abdomen or to retain 
dressings. 

10. Spica Bandage of one or both Groins. 

Length of roller, eight to ten yards ; width, two-and-a-half 
to three inches. 

Fi^. 54. 




Origin — Above the crest of the right ilium. 

Course — Two circular turns around the body above the 



88 



BANDAGING. 



crests of the ilia, thence obliquely downward across the groin 
to the inside of the right thigh to cover the right groin, to 
the outside of the left thigh to cover the left groin, around 
the thigh, across the groin obliquely upward to above the 
crest of the left ilium, and then to point of origin; repeat 
these turns, and cover one-half of each preceding turn, until 
the groin is covered (Fig. 54). 

Termination — Circular turns above the crest of the ilia. 

Fig. 55. 




Use — To make compression over the groin, as in case of 
bubo, or to retain dressings. To cover both groins, the turns, 
as described above, should be made to alternate (Fig. 55). 



BANDAGING. 



89 



11. The Spiral. Reverse 
of the Penis. Length of roller, 
eighteen to twenty-four inches ; 
width, one inch. 

Origin — Behind the glans penis. 

Course — Spiialand spiral reverse 
turns to the root of the penis. 

Termination — Root of the penis, 
fastened by slitting the terminal 
extremity and tying the two ends. 

Use — To retain dressings to the 
penis. 



Fig. 56. 




BANDAGES OF THE EXTREMITIES. 



SUPERIOR EXTREMITY. 

Bandages of the Hand. 

1. Spiral bandage of the finger. 

2. Spiral bandage of all of the fingers, or the gauntlet. 

3. Spiral bandage of the palm, or demi-gauntlet. 

4. Spica bandage of the thumb. 

1. Spiral Bandage of the Finger. Length of 
roller, one yard ; width, one inch. 

Origin — Circular turns around the wrist. 

Course — From the wrist across the back of the hand to 
the base of the finger, thence by very oblique turns to the 
point of the finger, returning to the base by spiral or spiral- 
reverse turns, and thence to wrist (Fig. 57). 

Termination — Circular turns around the wrist. 

Use — To retain dressings or to support parts in fracture. 
8* 



90 




2. Spiral Bandage of all of the Fingers, or the 
Gauntlet. Length of roller, eight yards ; width, one inch. 

Origin — Around the Avrist. 

Course — By turns, taking the same direction as those in 
the preceding bandage, each finger being covered separately, 

Fiff. 58. 




and the palm covered by spiral turns ascending to tlie wrist 
(Fig. 58). 

Termination — Circular turns around the wrist. 

iJse — To cover all of the finojers. 



BANDAGING. 



91 



3. Spiral Bandage of the Palm, or Demi- 
Gauntlet. Length of roller, six yards ; width, one inch. 

Origin — Around the wrist. 

Course — By circular turns around the wrist, thence down- 
ward across the back of the hand to the first interdigital 
space around the base of the finger, across the back of the 
hand to the wrist. Repeat these turns around the base of 
each finger until the back of the hand is covered. 

Termination — Circular turns around the wrist. 

Use — To retain dressings on the back of the hand. 

4. Spica Bandage of the Thumb. Length of 
roller, three yards ; width, one inch. 

Origin — Around the Avrist. 

Course — From the wrist across the base of the thumb to 
the phalangeal articulation, around the thumb, across the 

Fi?. 59. 




base of the thumb to the wrist, and continue these turns, 
covering one-half of each preceding turn, until the thumb 
is covered (Fig. 59). 

Termination — Around the wrist. 

Use — To make pressure over the base of the thumb, or to 
confine dressings. 



92' BANDAGING. 

Bandages of the Arm. 

1. Circular bandage of the wrist. 

2. Figure-of-8 bandage of the wrist. 

3. Figure-of-8 bandage of the elbow. 

4. Circular bandage of the arm. 

5. Oblique bandage of the arm. 

6. Spiral bandage of the arm. 

7. Spiral-reverse bandage of the arm. 

1. Circular Bandage of the Wrist. This bandage 
consists of two or more circular turns around the wrist. The 
spiral-reverse bandage of the upper extremity may begin by 
these turns passing by figure-of-8 to the hand and back to 
the wrist. 

2. Figure-of-8 Bandage of the Wrist. Length 
of roller, two yards ; width, two inches. 

Origin — Around the wrist. 

Course — Two circular turns around the wrist, over the 
back of the hand, to the palm of the hand, across the palm 
and over the back of the hand to the wrist; make two or 
more turns, covering one-half of each preceding turn. 

Termination — Around the wrist. 

Use — To make compression over the joint, or to confine 
dressings. 

3. Figure-of-8 Bandage of the Elbow. Length 
of roller, two yards; width, two inches. 

Origin — Around the upper part of the forearm. 

Course — Two circular turns around the upper part of the 
forearm, then obliquely upward across the front of the elbow 
to the lower part of the arm, making circular turns around 



r.ANDAGING. 93 

the arm and returning obliquely downward across the front 
of the elbow to upper part of the forearm ; then by ascending 
spiral turns covering the entire joint. 

Termination — Circular turn around the arm. 

Use — To make pressure over the elbow-joint, or to retain 
dressings. 

4. Circular Bandage of the Forearm or Arm. 

The application of tiiis bandage consists in making circular 
turns around any part of the forearm or arm. 

Use — To retain dressings or to compress the superficial 
veins in venesection. 

5. Oblique Bandage of the Forearm or Arm. 

Length of roller, two to three yards ; width, two inches. 

Origin — Around the hand. 

Course — Two circular turns around the hand, thence by 
very oblique turns up the forearm and arm to the shoulder. 

Termination — Circular turns around the upper part of the 
arm. 

Use — To retain dressings. 

6. Spiral Bandage of the Arm. Length of roller, 
three to five yards ; width, two inches. 

Origin — Figure-of-8 turn of the wrist and hand. 

Course — By spiral turns up the forearm and arm to the 
shoulder. 

Termination — Circular turns around the upper part of the 
arm. 

Use — To retain dressings. 

7. Spiral-Reverse Bandage of the Upper Ex- 
tremity. Length of roller, eight yards ; width, two 
inches. 



94 



BANDAGING. 



Fig. 60. Origin — Around the wrist by two 

circular turns. 

Course — From the wrist obliquely 
downward across the back of the hand 
to the metacarpo-phalangeal articula- 
tion, one or two circular turns around 
this articulation, thence obliquely up- 
ward across the back of the hand to 
the wrist, completing figure-of-8 turn 
of the wrist ; then spiral turns over 
the wrist-joint, ascending the forearm 
by spiral-reverse turns to the elbow, 
crossing the elbow-joint by figure-of-8 
turn and covering with spiral turns, 
and ascending the arm to the shoulder 
by spiral-reverse turns (Fig. 60). 

Termination — Circular turns around 
the upper part of the arm. 

Use — To support the arm in the 
treatment of fractures, dislocations, 
etc. 

This bandage may begin by circular 
turns around the hand, over the meta- 
carpo- phalangeal articulations, and 
then pass to the wrist by figure-of-8 
turns-. In passing over the wrist and 
elbow-joints, simple spiral turns should 

be made ; reverse turns increase the pressure and may do 

harm. 




BANDAGING. 95 

BANDAGES OF THE INFERIOR EXTREMITY. 

1. Figure-of-8 bandage of the ankle. 

2. Figure-of-8 bandagre of the knee. 

3. Figure-of-8 bandage of the thighs. 

4. Spica bandage of the instep. 

5. Spiral-reverse bandage of the lower extremity covering 
the heel. 

6. French spiral bandage. 

1. Figure-of-8 Bandage of the Ankle. Length 
of roller, two yards ; width, two inches. 

Origin — Around the leg, above the malleoli. 

Course — Two circular turns around the leg above the 
malleoli, thence obliquely downward in front of the ankle 
to the side of the foot, under the sole of the foot to the oppo- 
site side, obliquely upward in front of the ankle to the point 
of origin, making as many turns as may be required. 

Termination — Circular turns above the malleoli. 

Use — To cover in the ankle or to retain dressings. 

2. Figure-of-8 Bandage of the Knee. Length 
of roller, two yards ; width, two-and-one-half inches. 

Origin — Side of the upper part of the leg. 

Course — Two circular turns around the upper part of the 
leg, thence from side of the leg obliquely upward across the 
front or back of the knee to the side of the lower part of the 
thigh, circular turn around the thigh, then from opposite 
side of the thigh obliquely downward across the front or 
back of the knee to side of the leg, making the required 
number of figure-of-8 turns, and covering the joint by as- 
cending spiral turns. 

Termination — Circular turns above the knee. 

Use — To cover in the knee or to make compression. 



96 



BANDAGING. 



3. Figure-of-8 Bandage of the Thighs. Length 
of roller, live to six yards ; width, two and one-half" to three 
inches. 

Origin — Above the knees. 

Course — Beginning by circular turns above the knees, and 
making as many figure-of-8 turns as may be required to 
secure the limbs firmly together. 

Termination — Circular turns around the upper part of the 
thighs. 

Use — To fasten the thighs together after operations or 
injuries. 



61. 



4. Spiea Bandage of the Instep. Length of roller, 
six to eight yards ; width, two inches. 

Origin — Around the metatarso-phalangeal articulation. 

Course — By two circular turns around the foot, ascending 
by spiral-reverse turns to the instep, 
then obliquely downward to the point 
of the heel, the edge of the bandage 
projecting slightly below the border 
of the sole of the heel, around the 
heel, obliquely upward to the instep, 
downward to the side of the foot, 
under the foot to the opposite side 
of the foot and to the instep ; con- 
tinue these figure-of-8 turns, cover- 
ing one-half of each preceding turn 
until the instep is entirely covered 
(Fig. 61). 

Termination — Circular turn above the ankle. 

Use — To make firm compression over the instep or ankle. 




BANDAGING. 



97 



Ficj. 62. 



5. Spiral-reverse Bandage of the Lower Ex- 
tremity covering the Heel. Length of roller, ten to 
twelve yards ; width, two-and-one- 
half inches. 

Origin — Around the foot at the 
metatarso-phalangeal articulation. 

Course — Two circular turns 
around the foot, ascending by 
spiral-reverse turns to high up on 
the instep, thence over the point of 
the heel, back to the instep, under 
the sole of the heel, over the side 
of the heel, around the back of the 
heel, up to the instep, under the 
sole of the heel, over the opposite 
side of the heel, around the back of 
the heel up to the instep, then 
figure-of-8 turns of the ankle, spiral 
turns over the joint, spiral-reverse 
turns to the knee, figure-of-8 turn 
of the knee, spiral turns over the 
joint, and ascending the thigh to 
the hip by spiral-reverse turns 
(Fig. 62). 

Termination — Circular turns 
around the upper part of the thigh. 

Use — To support the limb after 
fracture, etc. 

This bandage may begin around 
the ankle and pass to the foot, 
covering it, and return by figure- 
of-8 turns to the ankle, and then ascend the limb. Reverse 
9 




98 



BAXDAGING. 



turns should not be made over the ankle or knee-joints, or 
over the crest of the tibia, owing to the increased pressure 

they exert. 

6. French Spiral Bandage. This bandage is ap- 
plied in the same manner as the preceding, the covering of 
the heel being omitted, passing from the foot to the leg by 
figure-of-8 turns. 



Fig. 63. 



GENERAL BANDAGES. 

Bandage of Seultetus. This bandage consists of a 
number of separate pieces varying in length, the first being 

sufficiently long to go 
once and a third around 
the upper part of the 
limb, each succeeding 
piece decreasing one 
inch. The pieces should 
be arranged so that each 
strip covers in one-third 
of that preceding. The 
limb is placed upon the 
strips arranged in order, 
and the application is 
commenced at the low- 
est part, crossing one 
strip over the other in 
an oblique direction 
(Fig. 63). 

Use — To support the 
limb in cases of com- 




BANDAGING. 



99 



pound fractures, etc., where it is advisable to avoid motion 
in removing dressings. 

Recurrent Bandage for Amputations. Length 
of roller, four to six yards ; width, two to two-and-one-half 
inches. 

Origin — Three to six inches above the end of the stump. 

Course — Two circular turns around the limb to the centre 
of the under surface, 

thence by recurrent -^^°* ^^' 

turns over the ex- 
tremity of the stump 
to the centre of the 
upper surface ; con- 
tinue these recur- 
rent turns on alter- 
nate sides of the cen- 
tral turn, covering 
in one-half of each 
preceding turn, un- 
til the stump is cov- 
ered. Fix the re- 
current turns by 
spiral or spiral-re- 
verse turns descend- 
ing to the end of 
the stump (Figs. 64, 
65). 

Termination — 
Circular turn 
around the stump. 

Use — To support the flaps of the stump after amputation. 




Figr. 65. 




100 



BANDAGING. 



Fig. 66. 



Velpeau's Bandage. Position of the arm; hand of 

the injured side grasping the sound shoulder. Length of 

roller, ten to twelve yards ; width, two-and-one-half inches. 

Origin — The axilla of the sound side. 

Course — Obliquely upward across the back of the chest, 

to the seat of the fracture, over 
the compress, covering the seat 
of the fracture, down across 
the outside of the arm to under 
the elbow, in front of the chest 
to the axilla of the sound side, 
thence by a circular turn across 
the back over the outside of 
the point of the elbow to the 
axilla of the sound side. Con- 
tinue the oblique and circular 
turns alternately, advancing 
over the arm and ascending 
from the point of the elbow until the arm is firmly supported 
(Fig. 66). 

Termination — By circular turn around the chest. 
Use — To support the arm in the treatment of fracture of 
the clavicle, the neck, or acromion process of the scapula. 

In applying this bandage, a compress of soft material 
should be placed between the arm and the surface of the 
chest to prevent excoriation. 

Desault's Apparatus. This consists of three single- 
headed rollers, a triangular pad to place in the axilla, and a 
sling to support the hand. 

The pad sljould be of such length as to extend from the 
axilla to the point of the elbow, and measure in width at 




BANDAGING. 



101 



the base from three to four inches. Length of rollers, eight 
yards ; "vvidth, two and one-iialf inches. 

First Roller. Origin — Over the apex of the pad ; 
placed in the axilla of the injured side. 

Course — Two circular turns around the chest over the 
apex of the pad, thence by spiral turns upward to the axilla, 
covering the pad and securing it in place. 

Termination — By circular turns around the chest. 

This roller can be dispensed with to advantage, and the 
pad held in place by tapes attached to its base passing 
around the neck. ' The arm should now be flexed at a right 
angle, pressing slightly against the side of the chest. 

Second Roller. Origin — Axilla of the sound side. 

Course — Circular turn across the front of the chest, over 
the upper part of the arm of the injured side, across the back 
of the chest to the point of origin, then by spiral turns de- 
scending to below the point of the elbow. 

Termination — Circular turns around the body. 

Use To throw the shoulder outward by pressing the 

elbow inward, using the 
pad as a fulcrum. 

Third Roller. Ori- 
gin — Axilla of the sound 
side. 

Course — Obliquely up- 
ward across the front of 
the chest to the seat of the 
fracture, over the seat of 
the fracture, down back 
of the arm to the elbow, 
under the elbow, across in 
front of the chest to the 



Fis. 67. 




102 BANDAGING. 

point of origin ; tlience obliquely upward across the back of 
the chest to the seat of the fracture, over the seat of the frac- 
ture, down in front of the arm, under the elbow, across the 
back of the chest to the point of origin (Fig. 67). 

Termivation — Circular turns around the chest. 

Use — To carry the arm upward and backward. 

It will be observed that two triangles are formed in apply- 
ing the third roller, the first having the base behind the arm, 
the sides across the front of the chest, and the apex in the 
axilla of the sound side; while the second has the base in 
front of the arm, the sides across the back o^ the chest, and 
the apex in the axilla of the sound side. 

Use of the Apparatus. — To support the arm and over- 
come its displacement in the treatment of fractures of the 
clavicle. 

THE COMPOUND BANDAGES. 

Under this name are included — 

1. The T bandages. 

2. The invaginated bandages. 

3. The sling bandages. 

4. The suspensory bandages. 

1, The T Bandages. These derive their name from 
their resemblance to the letter T, and consist of a horizontal 
portion, sufficiently long to surround the part to be covered, 
and a vertical piece half the length of the horizontal, firmly 
attached to its middle (Fig. 68). The bandage thus formed 
can be applied to various parts of the body. It is most fre- 
quently employed in retaining dressings to the perineum, 
when the horizontal portion is fastened around the body and 
the vertical band passed between the thighs and then attached 



BANDAGING. 



103 



to the horizontal piece. The Fig. 6S. 

napkin worn by women during (jjt 
menstruation is a familiar ex- 
ample of this form of bandage. 

2, The Invaginated 
Bandage. This bandage is 
formed by making strips or 
tails at the free extremity and 
at the proper distance cutting 
slits in the body of the band- 
age through which these tails pass. It was formerly used 
for the purpose of approximating the edges of wounds, but 
is now largely, if not altogether, discarded. 



Fiff. 69. 



Fig. 70. 





104 BANDAGING. 

3. The Sling Bandages. Tliese are made of pieces 
of muslin or other material of various lengths and widths, 
torn at each extremity into two or more tails, leaving a 
central portion or body (Fig. 69). They are quite useful 
in retaining dressings or supporting parts. In applying 
them, the central portion or body is placed upon the part, 
and the tails are carried in different directions about the 
part, and secured by pins or knots. The Four-Tailed or 
*' Poor Man's" Bandage is used in the treatment of fracture 
of the body of the lower jaw (Fig. 70). 

4. The Suspensory Bandages. These are made 
in the shape of bags or sacs of various sizes, and are used 
for the purpose of retaining dressings or supporting parts. 
They may be made of such material as is deemed most 
desirable. 

MAYOR'S SYSTEM OF HANDKERCHIEF 
DRESSINGS. 

This system of provisional dressings was introduced by 
M. Mayor, of Switzerland, in 1838. It consists in the use 
of the simple handkerchief, folded into various shapes, so 
as to accomplish the purposes of the roller. The dimen- 
sions of this kandkerchief vary according to the part to 
which it is applied, and may be made of any material which 
happens to be at hand. The forms into which the handker- 
chief may be made are : The Square, The Triangle, 
The Crayat, and The Cord. 

The Oblong Square is made by folding the handker- 
chief once on itself. 



BANDAGING. 



105 



The Triangle is made by folding the square so that 
the angles which are opposite come in contact. 

The Cravat is made by folding the handkerchief in 
the form of the ordinary cravat. 

The Cord is formed by twisting the cravat on itself. 

The handkerchief in the form of the Square may be 
employed to retain dressings over the head. 

In the form of the Triangle it can be used for the pur- 
pose of retaining dressings over the head (Fig. 71), the 
trunk, the shoulder, the elbow, the hand, the hip, the knee, 
and the foot ; also to support or retain dressings over the 
mammary gland (Fig. 72), to act as a sling for the arm (Fig. 

Fior. 72. 




r 



106 



BANDAGING, 



Fig. 73. 



Fig. 74. 





Fis. 75. 



base is to be applied to the part, and the angles carried about 

it and fastened by a knot. 

Tlie Cravat may be used to retain dressings, to make pres- 
sure, or to support parts, as the 
arm (Fig. 75). The body should 
be applied over the part, and 
the ends carried once or twice 
around the part and fastened by 
a knot. The handkerchief in 
the shape of the cravat may be 
used to fasten the foot to the 
end of the fracture-box in cases 
of fracture of the leg. It should 
be applied by a figure-of-8 turn, 
the body being placed over the 
tendo Achillis, and the ends 
carried across the instep and 




BANDAGING. 



107 



passed through the openings made in the end of the box, and 
then fastened by a knot. 

The Cord is used where it is necessary to make firm pres- 



Ficr. 76. 




Fior. 77, 




108 BANDAGING. 

sure, as when it is applied over a compress in cases of hemor- 
rhage. It may also be used in the form of the clove hitch 
for the purpose of making traction. The clove hitch is 
made by holding one end of the cord with the left hand 
and forming from the body a simple loop with the right 
(Fig. 76) ; holding this between the thumb and finger of 
the left hand, a second loop is made from the remaining 
portion of the body of the cord and lield by the thumb and 
finger of the right hand ; passing the second loop beneath 
the first, the hitch is formed (Fig. 77). 

IMMOVABLE BANDAGES. 

The Starch Bandage, the Plaster of Paris Band- 
age, AND the Silica Bandage. 

1. The Starch Bandage. In this form of bandage, 
the starch should be prepared so as to be of the same con- 
sistence as that used in the laundry. Before applying the 
roller, two compresses made of some soft material, folded so 
as to be at least one inch in thickness and of the same 
breadth as the limb, should be applied along each side, ex- 
tending from the point at which the application of the band- 
age begins to the point at which it terminates. Holding 
these carefully in position, the first roller is applied to the 
limb. This roller is now thoroughly coated with the starch 
by means of a medium-sized paint brush, the interstices and 
spaces being well filled. Over this a second roller is applied 
and coated with the starch in the same manner. In this 
way a sufficient number of rollers should be applied until 
the parts are properly supported. If necessary, strips of 
pasteboard which have been soaked in the starch may be 



BANDAGING. 109 

placed on the sides of tlie limb, after the second bandage has 
been applied, about those points requiring most support. 

The compresses, which are placed on the sides of the 
limb, serve the purpose of protecting it from undue pres- 
sure caused by the drying of the starched bandages. They 
may be applied dry, or they may be soaked in the starch 
and then applied. In the leg they are especially service- 
able in preventing pressure over the crest of the tibia, the 
two borders of the compresses, which are separated to a slight 
extent, supporting the bandage and keeping it from too close 
contact with the limb. 

2. The Plaster of Paris Bandage. This bandage 
may be applied with rollers made of some loosely woven 
material, such as crinoline, Swiss muslin^ cheese cloth, mos- 
quito-netting, or with the ordinary muslin. When the first 
is used, it should be cut into strips, and dry plaster rubbed 
with the hand into its meshes on both sides, and then the 
strips should be formed into rollers and put in an air-tight 
tin vessel. A^arious forms of apparatus have been devised 
to accomplish the impregnation of the material with plaster. 
That of Dr. William Judkins, of Cincinnati, is shown in 
Fig. 78. When required, the rollers should be placed ovi 
end in a basin, containing w^ater enough to cover them 
entirely, for one or two minutes, in order that they may 
become thoroughly wet, and in this condition they should 
be applied rapidly to the part ; a free escape of bubbles of 
gas through the water takes place, and when this has ceased, 
the bandages are ready for application. 

The roller, made of ordinary muslin, can be prepared 
by unrolling it in a basin containing water, thus becoming 
wet as it unrolls, and re-rolling it in a basin containing a 
10 



110 



BANDAGING. 



mixture of plaster and water of the consistence of cream. 
In this way the surfaces become well coated with the plas- 
ter, and the roller can be applied directly to the part. 




In applying the plaster bandage, the mixture of plaster 
should be rubbed over each roller with the hand after it is 
applied. The setting of the plaster may be retarded by add- 
ing a little size, a small quantity of borax, or stale beer. 
If salt is added, its tendency to set will be increased. Gum- 
water, white of egg, or flour-paste should be applied to the 
surface after hardening has occurred, in order to prevent 
chipping ; a coat of varnish will render it impermeable to 
moisture. In this form, the compresses should be placed 
along the sides of the limb in the same manner as in the 
starch bandage. In order to remove the plaster from the 
hands after the application of the dressing the white of egg 
may be used. 



BANDAGING. Ill 

3. The Silica Bandage. In preparing this bandage 
a solution of the silicate of potassium or sodium is used. 
The roller is applied to the limb over the compresses, 
placed as above described, and it is thoroughly coated with 
the solution by means of a medium-sized painter's brush. 
As many rollers as. may be deemed necessary are applied, 
each being thoroughly coated with the solution. 

This is an excellent form of the immovable bandage, 
being easily applied, lighter than the plaster bandage, and 
hardening in a very short time. 

4. The Dextrine Bandage. The solution of dex- 
trine is prepared by mixing thoroughly ten parts of dextrine 
with six parts of brandy or camphor, and adding to it four 
parts of warm water. In these proportions the mixture 
assumes the consistence of molasses, and may be applied in 
the same manner as the starch. 

5. Tripolith. This substance has been recommended 
by Prof, von Langenbeck as possessing advantages over 
plaster of Paris. It consists of lime, silicon, and oxide of 
iron, and after application it is stated to be lighter and more 
durable than plaster of Paris. Dr. Nelson, of Boston, has 
made several trials of it, and pronounces it to be unsatisfac- 
tory as a dressing. 

In addition to these forms of immovable bandages there 
are the Gum-and-Chalk, the Glue, the Glue-and-Oxide-of- 
Zinc, and the Paraffin bandages. These do not possess any 
advantages over those described above ; the end to be ac- 
complished — immobility of the parts — being secured by one 
as well as by the other. 

Great caution should be observed in applying the rollers 
in these forms of bandaore lest too much traction be em- 



112 



BANDAGING. 



Fig. 79. 




ployed ; they should be applied with less traction than the 
ordinary roller, owing to the shrinkage which occurs in some 
of them after application, and which thus increases the pres- 
sure. The parts should be carefully watched after the appli- 
cation has been made, in order to note any changes which 
may occur, indicating too much pressure or interference 
with the circulation. Should evidences of 
these conditions manifest themselves, the 
bandages should be immediately removed, 
the limb sponged with soap liniment or 
alcohol and laudanum, and the dressings 
re-applied with more care. 

In some forms of the immovable ban- 
dages, great difficulty is experienced in 
effecting their removal. Strong cutting 
pliers have been made, with which the 
bandages can be divided, the instrument 
being carried along the side of the limb 
(Fig. 79). To facilitate the removal of a 
plaster of Paris bandage, a band of flan- 
nel, saturated with unboiled linseed oil, 
with 5 per cent, of carbolic acid added, 
may be laid up and down the limb where 
the bandage is to be divided ; or, if very 
thick, dilute hydrochloric acid may be 
applied along the side for a few minutes, 
softening the plaster, so that it can be 
divided by the scissors. Saws with widely 
set teeth in the shape of that of Hey's, or 
the circular saw of Collin & Co., of Paris, 
are also used with advantage. The large 
burr or the circular saw of the surgical 
en«>ine can be applied, and in this way the bandage expedi- 




BANDAGING. 



113 



tiously divided. The starch bandage may be removed by 
one of these instruments. The phister of Paris bandage in 
some instances may be unrolled from the part. The silica 
bandage may be readily removed after soaking it for a time 
in warm water. 



Sayre's Sus- 
pension Appa- 
ratus for apply- 
ing the Plaster 
Jacket. This is 
an apparatus devised 
by Prof. Lewis A. 
Say re, of New York, 
for the purpose of 
suspending patients 
sufFeringfrom antero- 
posterior curvature of 
the spine during the 
application of the 
plaster of Paris baud - 
age. The object to 
be accomplished by 
the suspension of the 
patient, is the sepa- 
ration of the diseased 
vertebrae, and the 
straightening, to a 
certain extent, of the 
column, the bandage 
being applied when 
the patient is sus- 
pended. When it 



Fiff. 80. 




10* 



114 



BANDAGING. 



Yig. 81. hardens, it prevents the re- 

currence of the curvature to 
the same extent as before, by 
offering a firm support to the 
parts. 

The apparatus consists of 
a curved iron cross-beam, to 
which is attached an adjust- 
able head and chin collar, 
with straps fitted to axillary 
bands. To a hook in the 
centre is fixed a compound 
pulley, the other end of which 
is secured either to a hook in 
the ceiling, or to the top of 
an iron tripod about ten feet 
in height (Fig. 80). In ap- 
plying the plaster jacket, 
" the surface of the skin 
should be protected by an 
elastic but closely fitting shirt 
or vest, without armlets, with 
tapes to tie over the shoul- 
ders, and composed of some 
soft, warm, or knitted mate- 
rial ;" a thin and closely fit- 
ting merino undershirt can 
be thus prepared. When 
the patient is a developing 
girl, pads should be placed 
over each breast, to be re- 
moved just before the plaster has completely set. Another 




BANDAGING. 115 

pad, composed of cotton loosely folded up in a handkerchief, 
is to be placed over the abdomen ; it should be very thin at 
its lower part, so as not to make the jacket too loose. On 
the same principle, small pads are applied at either side of 
tender spots over prominent bony processes, and two folded 
cloths, three or four thicknesses each, just over the anterior 
iliac spines. The shirt being accurately applied, and kept 
smoothly stretched by means of the shoulder-tapes above and 
two tapes below, one in front and the other behind, tied over 
a handkerchief placed in the perineum, the patient is to be 
drawn up gently until he feels comfortable (Fig. 81). 

A prepared and saturated roller, gently squeezed so as to 
get rid of all surplus water, is now applied around the smallest 
part of the body, and carried around the trunk downwards 
to a little below the crest of the ilium, then spirally from 
below upward until the entire trunk is encased from the 
pelvis to the axillae. The bandage should be applied smoothly, 
and not drawn tight. 

" After one or two thicknesses of bandage have been thus 
applied, several narrow strips of roughened tin are laid on 
either side of the spine, so as to surround the body, with 
intervals between them of two or three inches. Over these 
another plaster bandage is applied ; very soon the plaster 
sets so firmly that the patient can be removed and laid upon 
his face or back upon a hair-mattress or air-bed. The pads 
are then removed, and the plaster gently pressed in with the 
hand in front of each iliac spine, so as to widen the case 
over the bony projections. While the patient is thus lying, 
it is sometimes "necessary to wet the jacket with a little 
water, and then dust on some more plaster. As soon as the 
plaster has hardened, the patient may be allowed to walk 
about." 



11 G BANDAGING. 

The jacket is generally removed, after two or three months, 
by dividing it with the cutting pliers, knife, or a very narrow 
saw, from the pubes to the sternum, and gently stretching it 
apart. 

Dr. Thos. J. Walker, of the Peterborough Infirmary, Eng- 
land, has described a method of applying the plaster of Paris 
jacket to the patient in the recumbent position. Bandages 
made of Victoria lawn are saturated with the plaster in an 
apparatus devised by him, then cut into strips and arranged 
as in the bandage of Scultetus (p. 98). One layer of strips 
(extending from the ilia to the axillse) is placed over the 
other usually to the number of two or three, until the requi- 
site firmness is obtained in the jacket. On these layers 
the patient is placed and the strips are overlapped one after 
the other in order. Mucilage is added to the plaster cream 
so as to retard the setting and thus give ample time for the 
application of the dressing. By this plan the dangers and 
discomforts of the suspension method are avoided as well as 
the alarm in case of children. 



PART III. 
FRACTURES. 



Definition. — A fracture of a bone is a solution of the 
continuity of its fibres. 

Varieties. — Complete and Incomplete. 

Complete fractures embrace, Simple or Single — Commi- 
nuted or Multiple — Impacted — Compound — Complicated — 
Epiphyseal. 

Incomplete fractures include Fissures — Punctures — 
Partial fractures. 

Complete Fractures Simple or Single Those in 

which there is one point of fracture only, dividing the bone 
into two pieces or fragments (Fig. 82). 

Comminuted or Multiple Fractures Those in which 

more than one point of fracture exists, the lines of separation 
communicating and dividing the bone into a number of 
pieces or fragments (Fig. 83). 

Impacted Fractures. — In this form one fragment of the 
bone is driven forcibly into the other so as to become fas- 
tened firmly in its position (Fig. 84). 

Compound Fractures In these there is a wound of 

the soft structures overlying the bone, so as to permit com- 
munication between the external surface of the part and the 
point of fracture. Where the fracture of the bone is com- 



118 



FRACTURES. 



minuted it is designated as a Compound-comminuted frac- 
ture ; or where complications exist, a Compound-complicated 
fracture. A fracture may be compound from the Jirst, or 
become so secondarily, as the result of morbid conditions 



Fiff. 82. 



Fig. 83. 



Fig. 84. 






which produce destruction of the overlying soft structures 
(Fig. 85). 

Complicated Fractures. — Fractures accompanied by dis- 
location of an adjacent joint, injuries of important blood- 
vessels or nerves, or extensive contusion and laceration of 
the soft structures, are designated complicated. 

Epiphyseal Fractures In this form of fracture a sepa- 
ration takes place between the epiphysis and the shaft of 
the bone — a condition liable to occur in young persons 
before ossific union has been accomplished (Fig. 86). 



FRACTUKES. 119 

Ficr. 85. Fig. 86. 




Z^' 



Incomplete Fractures Fissured fractures A fis- 
sured fracture is one in which there is a fissure or cleft in 
the fibres of the bone not extending through the entire 
structure. Lines of fracture radiating from a central point 
form the "stellate" fractures. 

Punctured Fractures. — In these there is a perforation of 
the osseous structure, without such separation of the fibres 
as to cause displacement. 

Partial Fractures This form of fracture is known com- 
monly as the " green-stick" fracture, in which part of the 
fibres break, the rest bending under the force applied : it 



120 



FRACTURES. 



occurs in young subjects, at that period of life when the 
animal matter predominates. 

Direction of the Line of Fracture The direction 

in which the fibres of the bone separate in fracture varies, 
being transverse^ oblique, or longitudinal. 

Transverse Line Tlie fibres of the bone separate at right 

angles to the long axis of the bone (Fig. 82). 

Oblique Line The oblique line of separation is that 

which occurs most commonly in fracture of the long bones 
as the result of force applied indirectly ; the fibres separate 



Fiff. 87. 



Fi-. 






at an angle of varying obliquity to the long axis of the bone 
(Fig. 87). 

Longitudinal Line. — The division of the fibres is parallel 
with the long axis of the bone (Fig. 88). 



FRACTUKKS. 121 



CAUSES OF FRACTURE. 



Predisposing and Exciting. — The predisposing causes 
include age^ sex, occupation, and diathesis. 

Age As age advances the relation between the propor- 
tion of organic and inorganic elements in the bones changes, 
the inorganic or earthy predominating to such extent as 
to render the bones fragile and liable to fracture on the ap- 
plication of force. 

Sex Males, by reason of their modes of life, are more 

exposed to the conditions which produce fractures than 
females. 

Occupation Occupation contributes to the occurrence of 

fractures in a marked degree. The daily work of the me- 
chanic and laborer exposes them to causes from which the 
merchant and professional man are exempt. 

Diathesis. — Certain diseases, as cancer, syphilis, rachitis, 
and other constitutional affections, produce such morbid con- 
ditions in the osseous system as predispose to the occurrence 
of fracture. 

The exciting causes of fracture are mechanical or external 
violence and muscular action. 

Mechanical violence is the most frequent cause, and may 
be applied in two ways : directly, or by direct application of 
the force to the part, and indirectly, or by counter-stroke, 
where the force is transmitted from a point of contact more 
or less remote. 

Muscular Action — Certain bones of the skeleton, as the 
patella, os calcis, and the olecranon process of the ulna, 
receive the attachments of powerful muscles, which, when 
called into extraordinary action, may exert such force upon 
the bones as to cause a separation of their fibres. Other 
11 



122 FRACTURES. 

bones, as the humerus, femur, and clavicle, may be subjected 
to fracture as the result of contraction of muscles attached 
to them, the body or limb being at the time in such position 
as to permit the bone to be taken at a disadvantage, as it 
were, the opposing action of other muscles being prevented. 

SYMPTOMS OF FRACTURE. 

The symptoms may be divided into the rational and 
'physical. 

The rational symptom are -pain and loss of function of 
the part or limb. 

Pain The degree of pain experienced varies in accord- 
ance with the nature of the fracture. A compound fracture, 
with extensive contusion and laceration of the soft structures 
would naturally cause greater suffering than a simple frac- 
ture ; frequently this symptom is absent, being elicited only 
in attempts at manipulation of the part. 

Loss of Function This condition may be complete or 

partial, depending somewhat upon the bones involved. Frac- 
tures of the femur and tibia prevent locomotion, while that 
of the humerus, ulna, and radius interfere with prehensile 
efforts. If not entirely destroyed, the function of the part 
may be stated to be always more or less impaired, the pain 
caused by efforts at movement contribute to this condition. 

The physical symptoms or signs include Deformity^ Mo- 
bility , and Crepitus. 

Deformity is the condition produced by the displaced 
fragments of bone, and is the result of various causes : — 

Is^. The force which is applied and which produces the 
fracture, continues to act upon the fragments and causes their 
displacement. 

2d. Muscular action The resistance offered to muscular 



I 



FRACTURES. 123 

contraction by the bone in its integrity is, after fractures, 
partially or entirely destroyed, and, as a result, displacement 
occurs in the direction of the muscular action. 

Direction of the Displacement The displacement may 

be longitudinal, angular, transverse, or rotatory. 

The longitudinal displacement is in the direction of the 
long axis of the bone, and causes, according to the bone 
involved, either shortening or lengthening; the former occurs 
most frequently in the fracture of the long bones where the 
line of separation is oblique and the ends of the fragments, 
as the result of muscular contraction, overlap each other; it 
also exists, to a less degree, in cases o^ impacted ivsidiwve. 

Lengthening, due to longitudinal displacement, is observed 
in fracture of the patella where the fragments are separated 
by muscular action. 

In angular displacement the fragments are placed at an 
angle to each other ; the fracturing force, assisted by mus- 
cular action, produces this form of displacement ; the angle, 
usually obtuse, may be increased in rare instances to nearly 
that of a right angle by the superincumbent weight of the 
body as in fracture of the femur, and union take place in 
this position. 

Displacement in the transverse direction occurs in frac- 
tures in which the line of fracture is transverse and the ends 
of the fragments are only partially separated. 

Rotatory displacement is tliat form in which one of the 
fragments rotates upon its axis so as to change the relative 
position of the surfaces ; it may take place in either frag- 
ment, and is the result of muscular action alone, or that 
combined with the weight of the limb. 

3c?. The weiglit of the part of the limb below the seat of 



124 FRACTURES. 

fracture, combined with muscular action, contributes to de- 
formity. 

Mobility. — Mobility is the movement which exists be- 
tween the ends of the fragments of bone, and is a character- 
istic siofti of fracture. In fractures near to or involvino^ an 
articulation, this symptom is of less significance unless it 
should be preternatural in character. In impacted fractures 
it is absent, or present in slight degree. In fractures of the 
forearm or leg in which but one bone is broken, the mobility 
is limited by the support given by the sound bone. 

Crepitus, — This is the sound produced by rubbing together 
the ends of the fragments of bone. It is most distinct in 
fractures involving the large bones of the skeleton, and can 
be in most cases as readily /e/^ as heard. It is to be distin- 
guished from the crepitation elicited in moving articulations 
in a state of disease, from that of inflamed bursae and sheaths 
of tendons, and from the crackling produced in emphysema- 
tous tissues ; the former is more of a dry, harsh, grating 
sound ; while the latter is softer and of a moist character. 
In incomplete and impacted fractures it is absent. 

In addition to the symptoms stated above and which are 
diagnostic in character, there may be enumerated swelling, 
discoloration, numbness, and muscular spasm. 

Swelling and discoloration accompany fractures in which 
more or less injury has been inflicted upon the soft tissues, 
producing extravasations and ecchymoses. 

Numbness and muscular spasm proceed from injury to 
adjacent nerves by the sharp, jagged ends of the bone-frag- 
ments. 

DIAGNOSIS OF FRACTURE. 

The diagnosis in fracture is to be made by careful exami- 
nation of the parts and study of the symptoms presented. 



FRACTURES. 125 

The eve, the ear, and the hand sliould be employed in tlie 
examination. Interrogations as to the manner in which the 
injury was received : inspection of the injured limb or part ; 
comparison with the sound side as to function, contour, po- 
sition, and relation of prominent surface markings; measure- 
ments from fixed points, and finally manipulation to ascertain 
mobility and elicit crepitus — all of these should be made in 
a careful and systematic manner. The examination should 
be made as soon after the receipt of the injury as possible. 
It is necessary, in cases w^here the pain caused by manipu- 
lation is severe and the symptoms are obscure, to administer 
an aniesthetic, so as to avoid giving pain and to overcome 
muscular resistance. In order to elicit crepitus, the ends of 
the fragments should be brought into apposition, the part 
grasped firmly above and below the seat of fi-acture, and 
gentle movement should be made in different directions. In 
fracture of the ribs crepitus can be sometimes felt and heard 
by placing the hand and then the ear over the seat of sus- 
pected fracture. In compound fractures the finger can be 
introduced into the wound and the seat of fracture explored. 
In all manipulations required to establish the diagnosis, the 
utmost gentleness consistent with thorough examination 
should be practised in order to avoid the infliction of addi- 
tional injury. 

PROGNOSIS IN FRACTURES. 

The prognosis as to the results after fractures, depends 
upon the age, condition of health, and habits of life of the 
patient, his co-operation with the surgeon during treatment, 
and the nature and extent of the fracture. The processes 
of repair in bone are favored by the vital energies of youth, 
robust health, and correct habits of life. A very important 

11* 



126 FRACTURES. 

element of success is perfect obedience on the part of the 
patient to the rules of treatment prescribed by the surgeon. 
In cases in which the directions of the surgeon are not fol- 
lowed by the patient, it is desirable to call a fellow-practitioner 
in consultation, in order that he may, in the event of the 
occurrence of a bad result, be able to bear testimony to the 
treatment instituted and thus exonerate the surgeon. The 
nature and extent of the injury influence largely the result. 
Fractures of bones of the trunk which enter into the forma- 
tion of cavities, as the vertebrae, ribs, pelvis, are liable to be 
complicated with injuries of the contained viscera and thus 
render the prognosis unfavorable. Compound and compli- 
cated fractures in any part of the body, and fractures near 
to or into an articulation, involve a doubtful prognosis. 

Process of Repair in Fractures. — The parts involved in 
the fracture of bones are the external covering, the perios- 
teum ; the bone tissue proper, compact and cancellous ; and 
the medulla, with its membrane, the medullary membrane or 
internal periosteum. For the purpose of convenient study 
the processes concerned in the repair may be divided into 
stages. 

1st Stage, In all fractures, an extravasation of blood to 
a greater or less extent occurs as a result of the laceration of 
the bloodvessels of the tissues involved. The removal of 
this extravasated blood may be accomplished by absorption, 
ejection by suppurative action, or it may become organized 
and form part of the reparative material. 

'2d Stage. The second stage includes all of the processes 
which are concerned in the union of the fragments, and may 
be designated the "uniting stage." After the removal of 
the extravasated blood is accomplished, or while this is being 
effected, the true reparative material begins to be formed, 



FKACTURES. 127 

the periosteum and the medullary membrane taking active 
part. This material, known as callus, appearing first as a 
granular substance, may, according to circumstances, pass 
through several transitional forms before ossification is ac- 
complished, as fibrous tissue, fibro-cartilaginous tissue, and 
cartilage, or it may be transformed from rudimentary states 
directly into bone. It is deposited by the osteo-genetic 
layer of the periosteum about the external surfaces of the 
ends of the fragments forming the external or ensheathing 
callus, within by the medullary tissue forming the internal 
or pm callus, and, finally, by the bone tissue between the 
ends of the fragments constituting the intermediate or defini- 
tive callus. The extent of production and deposit of this 
callus depends upon the adjustment of the ends of tlie frag- 
ments and their maintenance in a fixed position. Accurate 
coaptation of the extremities of the fragments and absolute 
immobility reduces its production to a minimum degree by 
the protection afforded the lacerated surfaces by their coap- 
tation and the prevention of irritation by immobility. In 
compound fractures where the wound is exposed to the air, 
and more or less suppuration occurs, the callus or repara- 
tive material is developed through the medium of granula- 
tions, which finally undergo ossification. 

In some cases an arrest in the complete development of 
the reparative material may take place and the fragments 
may be united by fibrous tissue forming an ununited frac- 
ture. 

3rf Stage. This stage in the repair is occupied in the 
" modelling" or shaping of the parts about the seat of frac- 
ture. If the coaptation has been accomplished accurately, 
and the fragments kept quiet, there is little to be done in 
this stage. If the adjustment has been imperfect, the frag- 



128 FRACTCli£S, 



OTcrlappeds and the nedoDaij t --^ - ^ - "? 
w«Mt of this sta^ win cosast in tbe Tr _ ^^ 

caJliK if present^ and the roondii^ off ot the sharp ends of 
the fiagmenls 1^ ahsmpcion, the capping of the exposed ends 
of the fin^ments by new bone formation, the shaping of the 
cdoe deposited b^twe^i the fragments and the fonaation of 
an external wall and a eanedloQs inteiior for it continiioas 
with the <^ and, finalfy, the lestoraticm of the mednllaij 



The time leqaired for the enajj^etion of Ae rqpaiatiTe 
pnice^ varies aceoidiii^ to the bone initdved and the na- 
ture and extent id the fiactore. In simple fiactmes the 
first wedk aSkct the injoiy is occaqpied in the maoTal of the 
inflammation which is consequent opon the injoij to the 
parts and of its products. From this period to the end of 
the third we^ the formation of the caDos and its gradnal 
deT^opaient oecms; after the third wec^, and to the tenth 
and twelfth, oi^fication is perfected and the ftagments are 
eoDfifdidated. 

TUEJlTHEST of FJLLCTITKE^, 

The treataMnt of fiactores indodes the trai^portation of 
the patient, prqiaration of the bed, the lednctioB or setting 
of the fn^moiis, then* retention in place until onion k ae- 
co mpljylie d, and, finallj, the treatmoit €if all conditioiK 
aiiai^ during the period cf r^air. 

TrttmsjtnwtaAvm. ^ U» PaticHL — ^In fiactores other than 
those of the i^per extranitj it is neee^arj that the patioit 
^oold be carried to the place of treatm»it. When the dis- 
tance is great, thisshooldbedoneinaTeiiicleof somekind, 
prefeiaM J an ambolance <Mr furnitur e car. in which the recum- 
bent posture can be maintained. If transported bj land he 



FRACTURES. 129 

should be placed upon a door, shutter, or settee, and this 
borne upon the siioulders of four strong men. Some soft 
and firm substance, as pillows, mattress, comfortables, or 
blankets, should be placed under the body and fractured 
limb or part, and this should be supported by temporary dress- 
ings so as to fix the fragments and prevent injury and pain. 
In the lower extremity the sound limb can be utilized as a 
splint, the injured one being bound firmly to it by large 
handkerchiefs, or broad strips of muslin applied at two or 
more points in figure-of-8 manner. Fractures of the pelvis, 
the vertebrae, or ribs, can be held in position during trans- 
portation by broad pieces of muslin, such as pillow or bolster 
cases carried about the body once or. twice. The bones of 
the head and face can be supported by handkerchiefs applied 
in cravat form. 

In fractures involving the upper extremity, including 
scapula and clavicle, the limb should be supported in a sling 
formed of a broad handkerchief in triangular form. 

Preparation of the Bed. — The bedstead should be strong, 
and the mattress tightly stuffed so as to be firm and unyield- 
ing. A single or narrow iron bedstead, w^ithout a foot-rail, 
with short legs, and a firm hair mattress, is the best which 
can be selected for the patient sufifering from fracture. In 
cases of fractures of the pelvis, vertebrae, or lower extremity, 
it is necessary that arrangements should be made for evacua- 
tion of the bowels without movement, and to accomplish this 
most successfully, a round opening should be made in the 
mattress and overlying sheet, beneath which the vessel for 
the reception of the feces can be placed. The surfaces and 
borders of the opening in the mattress should be lined with 
oilcloth, and the piece cut out should be covered and pre- 
pared so as to fit into the opening tightly, being placed in 



130 FRACTURES. 

position from beneath wlien not needed for use. In the 
iron bedstead the spaces between the slats are wide enough, 
and the vessel can be brought sufficiently near by placing it 
on a stool or block so as to obtain proper evacuation of the 
feces. 

A narrow wooden bedstead, with slats, can be arranged 
and used in the same way, or changed by introducing a 
broad slat in the middle, w^ith an opening in it, and cleats 
attached beneath, so tliat the vessel for reception of the feces 
can be slid into place and withdrawn after use. If neither 
of these are available, the ordinary rope bedstead, now 
largely out of use, can be made suitable by substituting 
slats, which can be nailed to the rails, upon which a firmly 
packed straw or husk mattress, covered, if necessary, with 
comfortables to make it firmer, can be placed. Where no 
opening exists in the mattress the bed-pan can be placed 
in position without causing much, if any, motion. 

In cases w^iere it may be necessary to employ the air or 
water-bed, a cheap substitute for those found in the shops 
may be provided in the following way : a trough the length 
and width of the single bedstead, one foot and a half deep, 
can be filled w^ith water, and then covered with a stout rub- 
ber cloth, which should be firmly secured to the sides. Upon 
this the bedclothes can be placed, and the patient made 
very comfortable. 

Whatever form of bed is selected, whether such as the 
patient of wealth is able to provide, or such as is available 
to the poor, it should be the duty of the surgeon to have it 
made so as to afford firm and even support to the fractured 
limb or part, provided with appliances for the ready evacua- 
tion of the bowels without imparting movement, and in 



FRACTURES. 131 

every way conduce to the comfort of the patient, who is 
compelled to occupy it for a long period of time. 

To remove the weight of the bedclothing in cases of frac- 
tures of the lower extremity, a rack or cradle should be pro- 
vided : two half hoops crossed and fastened will serve the 
same purpose. 

Bemoral of the Clothing The clothing of the patient 

should be removed with as much gentleness as possible. If 
it is necessary to cut it, this should be done in the seams 
so that they can be repaired readily. A little care and tact 
will enable the surgeon or his assistants to remove any or 
all of the articles of clothing without giving unnecessary 
pain or causing disturbance of the fragments. When the 
patient is in bed, the underclothing should not be drawn 
beneath the buttocks, as it is liable to become rumpled or 
folded in this position, causing discomfort and pain, con- 
ducing to the formation of bed-sores, and also it is more 
liable to become soiled. 

Changing the Bed-linen. — The sheet overlying the mat- 
tress should be removed by drawing it from above dow^n- 
wards. Being first loosened at the top of the mattress and 
pushed down beneath the shoulders, the clean sheet is folded 
and carried under the shoulders to the same point, the upper 
end being placed in position under the mattress at the top. 
"While the pelvis of the patient is raised gently, the soiled 
sheet, having been fastened with pins, or better, by stitches at 
two or more points in the middle to the clean sheet, is drawn 
down in this way, placing the latter in position. The sheet 
covering the mattress should be firmly stretched over it and 
secured by pins at the sides and top so as to prevent folding. 

Reduction or Setting of the Fragments This consists in 

adjusting the ends of the fragments to as nearly as possible 



132 FRACTURES. 

a normal position, and is accomplished by extension, counter- 
extension, and manipulation. 

Extension is the force applied to the distal part, and is best 
effected by grasping the part some distance below the seat 
of fracture, the hand in the upper and the foot in the lower 
extremity, and making firm, but equable traction, increas- 
ing the force gradually so as to avoid the production of mus- 
cular spasm. An anaesthetic agent should be administered 
in all cases where the muscular contraction interferes with 
the proper adjustment of the ends of the fragments. 

Counter -extension is the force applied to the proximal 
part, and opposes the efforts of extension. It should be ap- 
plied at some distance above the seat of fracture, and should 
be made with the same care as extension. Holding the 
part firmly is all that is needed in the way of counter- 
extension in most cases. 

Manipulation Manipulation is made by the fingers for 

the purpose of coaptating or placing in apposition the ends 
of the fragments. In this way pressure and counter-pres- 
sure can be made as well as all of the movements necessary 
to secure a proper adjustment of the fragments. 

Retention of the Fragments in Position This is accom- 
plished by means of bandages, splints, and other dressings. 

Bandages. — In the treatment of fractures, bandages 
should be used simply as supporting and retentive dressings, 
and all compression with them should be carefully avoided ; 
as a rule they should therefore be applied outside of the 
splints ; especially is the rule to be observed in the early 
stages of fractures when inflammatory action is severe. After 
the subsidence of inflammation they may be applied with 
care for the purpose of giving support to the parts. When 
used in the form of immovable dressings (page 108) they 



FRACTURES. 133 

assume the duty of splints, and in these cases should always 
be applied with cure, and their effects should be closely 
watched. In simple fractures, where the injury to the soft 
tissues has been slight, they may be employed as primary 
dressings; they serve a useful purpose after the removal of 
the dressings which have been used in tlie treatment of frac- 
tures in supporting the repaired bone during convalescence. 

Splints. — Splints are appliances which are employed for 
the purpose of maintaining in the proper position, during 
repair, the ends of the fragments. 

The materials whicli are employed in their construction 
are very numerous. The. list includes wood, binders' board, 
pasteboard, paper, gutta percha, sole leather, felt, tin, zinc, 
lead, wire, sheet iron, plaster, with the various agents used 
in the preparation of immovable dressings. Besides these, 
in cases of emergency, straw sewed in between two pieces of 
strong cloth, the bark of trees, or the crust of a loaf of bread 
(for lower jaw), may be employed with good effect as splints. 

Wood This material is used more frequently than any 

other in the construction of splints. Wooden splints should 
be made of some light and soft wood, such as pine, willow, 
or linden. Pieces of these various kinds, of uniform thick- 
ness, should be kept at hand, from which splints can be made 
to suit each individual case. Carved wooden splints, such 
as are found in the shops, are objectionable as a rule, owing 
to their want of proper adaptation to particular cases. Prac- 
titioners employing splints of this character are liable to so 
adjust the fragments of a fracture as to make the injured 
limb fit the splint instead of securing a proper application of 
the splint to the adjusted fragments. By means of com- 
presses and pads such arrangement of the surface of the 
12 



134 FRACTURES. 

splint can be obtained usually as will meet the indications 
present. 

Binders^ Board This substance, which, as its name 

indicates, is used by book-binders for making book covers, 
is, in common with card-board and pasteboard, employed 
to great advantage in the formation of splints. These mate- 
rials are valuable by reason of their cheapness and their 
presence in the house of patients in some form, and of the 
ease with which they can be softened by immersion in water, 
preferably that which is hot, at the time of application, and 
immediately moulded upon the part. Caution must be exer- 
cised with regard to the length of time of immersion of the 
material, as it becomes too much softened and separates into 
pieces if kept for too long a time in water. Especially does 
this caution apply to the thinner substances, as card-board 
and pasteboard. Usually it is sufficient to dip the pieces 
in the water once or twice, and then mould them to the 
part. Splints made of these materials should be padded 
with a layer of cotton-wool, or some tiiick, soft substance, 
and then retained in position by turns of the roller. They 
dry readily, and form a firm and well-adapted support to the 
adjusted fragments. Binders' board is to be used in cases 
of fracture of large bones, and in adults, while the paste- 
board affords sufficient support in small bones and in frac- 
tures occurring in young children. 

Paper Strong paper, such as is used in hardware and 

other stores for wrapping purposes, can be cut into pieces 
and fastened together by starch, white of egg and flour, or 
gum Arabic, thus forming a firm and stiff support. The 
pieces may be made so as to quite surround the limb, or cut 
into strips and placed as lateral supports. 

Sole-Leather. — This substance is well adapted for the 



FRACTURKS. 135 

purposes of forming splints by reason of its flexibility and 
firmness. It should be cut into pieces of suitable size, and 
after being soaked it can be easily adapted to the limb. In 
twelve to twenty-four hours it will become hard and can be 
removed, and the dressing readjusted. In order to prevent 
undue pressure by the edges and corners of the splint, these 
should be bevelled and rounded. It siiould be padded with 
layers of cotton-wool or soft woollen cloth. Strips of light 
wood can be glued to the surface of thin calf-skin or buck- 
skin, and in this manner combine the additional firmness of 
the wood with the flexibility of the leather. 

Gntta-Percha Owing to the difficulties which attend 

the successful manipulation of this substance in the form- 
ation of splints, it has fallen somewhat into disuse. For the 
construction of the inter-dental splint in cases of fracture of 
the lower jaw and alveolar process of the upper, it is of the 
greatest value. For this purpose the vulcanized India- 
rubber is regarded as best adapted. The ordinary gutta- 
percha can be softened by immersion in hot water and 
moulded to the parts as in other fractures. 

Care should be taken always to place the strip of gutta- 
percha upon a piece of strong muslin of sufficient width and 
length to enable it to be handled conveniently before it is 
moistened with the hot water, otherwise it will adhere to the 
tray in which it is placed and to the fingers of the surgeon. 

Felt This material has been employed quite extensively 

by Dr. Ahl, of York, Pa., for the formation of splints, which 
are found on the shops already shaped for different parts of 
the body. It consists of wool, or wool and fur, moistened 
with size or gum shellac and then pressed into sheets. Dr. 
Hamilton describes an excellent substitute, and one which is 



136 



FKACTUEES. 



much cheaper, made from four to six layers of cotton cloth 
saturated with gum shellac and smoothly pressed. 

Metal Splints — Metals of various kinds, as tin, zinc, lead, 
sheet iron, iron wire, and copper, have heen employed for 
the purpose of making splints. The weight of these materials 
and the time required to fashion them into proper shape, 
make their selection undesirable. 

Plaster of Paris This, with starch, dextrine, and other 

substances possessing similar properties, is largely used in 
the formation of fracture dressings. They are designated 
as the immovable dressings. Latterly these dressings have 
been applied in such manner as to render them easily re- 



Fig. 89. 



Fig. 90. 





moved and at the same time not interfere with their char- 
acter as well adapted and firm supports. In this condition 
they are called movahle-immovahle dressings or apparatus 
(Figs. 89 and 90). While this form of dressing possesses 



FRACTURKS. 



137 



many advantages, it is not entirely free from danger, as the 
recorded cases of bad results bear testimony. In cases ot 
very simple fractures, unattended by injury of the soft tis- 
sues, it may be safe to apply immediately the immovable 
dressin-s. On the other hand, in cases of fractures which 
are the^esult of great violence, and in which the soft struc- 
tures are much contused with a tendency to the production 
of inflammatory swellings, these dressings should not, as a 
rule, be applied immediately ; if so applied, they should be 
watched with the utmost care, being so arranged as to be 
removed at intervals with ease and the parts inspected. 
When applied in the treatment of compound fractures, an 
opening or " trap-door" should be made over the wound so 
as to permit of the free escape of the discharges and of the 
application of suitable dressings (Fig. 91). In cases of 

Fig. 91. 




^y 



compound fracture or excision of joints or bones in which it 
is necessary to treat large wounded surfaces, plaster splints 
may be applied in sections and the two united by bars of 
wood or metal (Fig. 92). 

In the employment of any splint, it matters not of what 
12* 



138 FKACTUKES. 

material it is made, great care should be taken always to 
pad it well or place between it and the surface layers ol 




some soft substance in order that a proper adaptation to 
the inequalities of the limb may be secured, proper support 
afforded, and undue pressure avoided. 

Splints may be padded conveniently by placing over the 
inner face or that to be applied to the surface, a sufficiently 
thick layer of cotton-wool, oakum, curled hair or other sub- 
stance of like character, and holding it in place with a roller 
applied by spiral reverse turns and recurrent turns over the 
ends. Another method of padding consists in placing the 
splint in a muslin sock open at both ends into which the 
cotton-wool or other material is stuffed, in this manner form- 
ing a soft and firm cushion upon tlie side which is placed 
in contact with the limb. In all cases it is desirable to 
cushion the splint rather than apply a separate cushion or 
pad of loose material between it and the limb. These are 
liable to become displaced, or to lose their accurate adapta- 



FRACTURES. 130 

tioii to the part. Sometimes masses of cotton-wool may be 
employed to fill up spaces between the splint and limb so as 
more completely to protect the part and afford support; as a 
rule their use should be avoided, or they should be used 
only to supplement the cushioned splint. 

In order to retain the splint in position the roller should 
be applied with sufficient traction to accomplish this object 
without making undue pressure. In some instances, Avhere 
a tendency to displacement exists it may be found necessary 
to apply the retaining bandage with more firmness, but 
great caution is to be exercised in order to avoid making 
too much traction, in this way causing interference with the 
circulation and possible gangrene of the limb. As in the 
application of the roller, where it is used as a primary or in- 
dependent dressing, the sensations of the patient should be 
consulted, and the condition of the distal portions of the 
limb should be examined carefully and repeatedly. 

As far as possible fracture dressings should be simple in 
construction, the materials composing them cheap and readily 
obtained, they should be comfortable to the patient, easily 
applied and removed. They should be made as light in 
weight as is consistent with proper support. Heavy and 
cumbersome dressings are apt to prove fatiguing to the 
patient and to provoke an unrest of the parts which may 
interfere with the reparative process. Elaborate and com- 
plicated dressings are not only difficult of application, but 
are liable to become disarranged, and in this way to cause 
displacements of the fragments with resulting deformities. 

Sand-hags Bags made of strong muslin, and of suitable 

length and width, filled with dry sand, are used to.affiDrd lat- 
eral support in fractures of the lower extremities. 

Adhesive Plaster — This material is used in fractures for 



140 



FRACTURES. 



the purpose of affording support, and in the lower extremity 
to secure extension (Fig. 93). 

Weights and Pulleys These are employed to maintain 

extension in the treatment of fractures of the femur. The 



Fiff. 93. 



Fig. 94. 



Fig. 95. 





Fig. 96. 




pulleys can be adjusted by a simple arrangement to the foot 
of the bedstead, or on an upright frame (Fig. 94), and 
bricks, pound weights, or shot can be used as weights. 



FKACTURKS. 141 

The cord holding tlie weights is fastened to a block which 
is secured in position between two pieces of adhesive plaster 
(Figs. 95-96). 

When this method is used, counter-extension is obtained 
by raising the foot of the bedstead so that the body of the 
patient becomes the counter-extending weight. 

Time for Reducing a Fracture. — The reduction and 
dressing of a fracture should be accomplished as soon after 
the occurrence of the injury as possible. If delay has 
occurred until severe inflammatory action is present, then a 
temporary dressing should be applied and sorbefacient lotions, 
as laudanum and lead-water, should be used locally. On 
the subsidence of inflammation reduction should be effected 
and a permanent dressing applied. 

In cases where dressings are not at hand so that they can 
be applied immediately, the limb should be placed in a com- 
fortable position and the fragments held by a temporary 
dressing. 

Reneioal of the Dressings. — The condition of the limb or 
part, and of the dressings, will be the guide to be followed 
in the renewal of the dressings. In fractures, other than 
those of the lower extremity, it is a safe practice to remove 
the dressings at the expiration of twenty-four hours, inspect 
the parts, so as to ascertain whether the adjustment is proper, 
and renew the dressings carefully. Especially is this neces- 
sary where there is pain, swelling, or other evidences of 
undue pressure. In the lower extremity the parts can be 
inspected usually without removal of the splints, and any 
constriction which may exist can be relieved. After the 
first day the outer dressings can be renewed ever}' forty- 
eight hours, if necessary, for the first week or ten days. 
After this the dressings should not be disturbed as lonoj as 



142 FRACTURES. 

tliey are in proper position. It should be remembered that 
perfect quietude of the fragments is essential to speedy and 
proper union, and that frequent renewals of dressings are 
liable to disturb them, and should, if possible, be avoided. 
During the entire course of treatment vigilance should be 
exercised, and the part kept under close observation, daily 
visits being made until the process of repair is well advanced^ 
At the time of renewal of the dressings the limb should be 
firmly and carefully supported by assistants, so as to prevent 
displacement, and the surface should be sponged with dilute 
alcohol or soap liniment, and then dried thoroughly. 

Removal of Dressings, — The limb involved and the na- 
ture of the injury determine the period at which it is safe to 
remove the permanent dressings. They should be retained 
from four to six weeks in fractures of the upper, and from 
live to eight in the lower extremity. After their removal, 
in all cases, bandages should be applied to afford support 
while the limb resumes gradually and carefully its functions. 
The part should always be examined carefully to ascertain 
that union is perfect before the permanent dressings are 
dispensed with. 

Passive Motion The absolute rest essential in the treat- 
ment of fractures subjects the articulations contiguous to the 
bones involved to disuse, and as a result they become stiff 
and rigid. To overcome this impairment of function, pas- 
sive motion, producing flexion, extension, or rotation if 
necessary, should be instituted gently and carefully at the 
expiration of from eight to twelve or fourteen days, and 
should be repeated at short intervals. The efforts necessary 
to accomplish movement of the joint should be made very 
cautiously, and the limb should be supported firmly by the 
assistants. Frictions with emollient and stimulating lotions, 



FRACTURES. 143 

as oil, dilute alcohol, soap liniment, and other agents of this 
character, should be made over the joint. When the frac- 
ture extends into a joint greater care is required in practis- 
ing passive motion so as to avoid separation of the fragments. 
In these cases it should be persevered in, in order, if possi- 
ble, to prevent anchylosis. 

Conditions occurring during the after-treatment. — Mus- 
cular spasm, due to the irritation produced by the jagged 
ends of the fragments, is controlled best by hypodermic in- 
jections of morphia, one-sixth to one-quarter of a grain. 

Conttisions and Extravasations. — When these conditions 
are present to any marked degree the limb should be envel- 
oped in cloths saturated with evaporating lotions. They 
may be applied with the dressings in position, or, in severe 
cases, it may be necessary to defer the application of the 
permanent dressings, placing the limb temporarily on a pil- 
low, and continuing the use of the lotions until the inflam- 
mation subsides. 

Gangrene — This grave condition may occur as the result 
of arterial or venous obstruction, which may be due to the 
injury or to the pressure caused by tight bandaging. When 
caused by the latter, the treatment consists in the prompt 
removal of all constriction, with the hope of limiting the 
morbid action. If the gangrene becomes complete, ampu- 
tation should be performed, at the line of demarcation, if 
one is present; or, in the spreading variety, a point some 
distance beyond the limits of the disease. 

Excessive Inflammation^ Erysipelas, Tetanus, Surgical 
Fever and Pycemia are conditions which may occur after 
fracture, and require treatment as in other affections. 



144 FKACTLRES. 

TREATMENT OF COMPLICATED FRACTURES. 

Rupture of the Main Artery sometimes occurs as a com- 
plication in fracture. It is a serious accident, and is diag- 
nosticated by the rapid swelling of the limb and the absence 
of pulsation in the arteries below the seat of injury. Fre- 
quently an ill-defined pulsation exists in the swelling. An 
effort to save the limb may be made by ligating at once the 
artery above the seat of injury. If the collateral circulation 
is not re-established gangrene will develop, when amputation 
must be performed. 

Injury of Important Nerves. — Paralysis, partial or com- 
plete, is liable to follow injury of principal nerves in fracture, 
and should be treated by electricity, frictions, and otiier 
means, with a view to restore the lost power. If recognized 
at the time of the injury, the patient should be informed of 
the unfavorable prognosis. Repair of the fracture is not 
interfered with. 

Involvement of an Articulation The treatment of a frac- 
ture implicating a joint requires great care, as the injury may 
be followed by anchylosis. In the large joints the condition 
may demand excision or amputation. 

Dislocation accompanying Fractures — The dislocation 
of an adjoining articulation sometimes occurs. Temporary 
splints should be applied, so as to support the broken bone, 
the luxation reduced, and then the fracture should be per- 
manently dressed. 

Fractures occurring in persons suffering from delirium 
tremens, epilepsy or chorea, are seriously complicated, and 
the treatment demands special care. In cases of mania a 
potii the patient should be strapped to the bed, and a well- 
padded splint of binders' board or felt should be moulded to 



FRACTURES. 145 

the limb and secured with a bandage. Appropriate remedies 
should be given to I'elieve the delirium. In patients suffering 
from epilepsy the fracture should be well supported by proper 
splints and the patients should be kept under the influence 
of bromide of potassium. The treatment of fracture in cho- 
reic patients is very unsatisfactory, owing to the impossibility 
of keeping the fragments at rest. In a case reported by 
Dr. Wm. Hunt of this city, death occurred on the tenth day 
from exhaustion. 

Treatment of Compound Fractures. — In the treat- 
ment of compound fractures the question of amputation is 
always to receive consideration. The operation is, as a rule, 
demanded in those cases in which extensive injury is done 
to the soft tissues; large arteries wounded; large joints 
implicated, or where the bone is greatly comminuted. It 
should be performed a«! a primary operation before inflam- 
mation has supervened; ir' delayed until this period it should 
not be done until suppuration is fully established. In all 
cases the surgeon should exercise the best judgment, consid- 
ering carefully the conditions presented in each case and the 
chances afforded the patient in an effort to save the limb. 

In cases in which amputation is not required, an effort 
should be made after reduction and the application of proper 
splints to convert the fracture into that of the simple variety 
by closing the external wound. This may be accomplished 
where the wound of the soft structures is small, by the appli- 
cation of adhesive plaster, collodion and gauze, antiseptic 
dressings, or a piece of lint saturated with the blood from 
the wound. After closure of the wound it should be care- 
fully watched, in order to ascertain whether pus is accumu- 
lating beneath the dressings. In the event of its formation 
the dressings should be immediately removed and the escape 
13 



146 FRACTUUES. 

of the discharges promoted. In large wounds no effort should 
be made to obtain permanent occlusion. Appropriate dress- 
ings should be placed over the wound, and precautions should 
be taken to secure free drainage. Tlie splints and bandages 
should be applied so as to admit of ready inspection of the 
wound without disturbance of the limb or part, and should 
be protected by oiled silk or waxed paper, so as to prevent 
soiling by the discharges. 

Reduction is accomplished, as in simple fracture, by ex- 
tension, counter-extension, and manipulation. If the frag- 
ments project through the wound, their reduction may be 
facilitated by the administration of an anjesthetic agent and 
placing the limb in such position as to cause relaxation of 
the muscles, and by separating the edges of the wound with 
retractors ; or, if necessary, the wound may be enlarged by an 
incision. Resection of the projecting fragments should be 
performed only when all other means of reduction fail, and 
then as small a portion as is absolutely necessary sliould be 
removed. If the periosteum is stripped off, as may happen 
most easily in young subjects, it should be replaced over 
the surface of the bone, in the hope that reunion will ensue 
and necrosis be thus prevented. 

In compound fractures in which the bone is comminuted 
it will be necessary to remove the fragments or splinters 
which are completely detached. Those having sufficient 
periosteal attachment to insure proper blood supply should 
be carefully adjusted and allowed to remain in position. If 
sequestra are formed, they are to be removed as soon as suffi- 
ciently detached. The inflammation which ensues should 
be treated by the administration of such remedies, and the 
application of such dressings, as will control its effects upon 
the system and limit its extent. Antiseptic dressings, cold- 



FRACTURES. 147 

water applications, poultices, etc., may be employed locally, 
as the conditions of each case may demand, whilst iron and 
quinine, with stimulants, may be given to maintain the pa- 
tient's strength under the suppurative action. 

Treatment of Fractures united with Deformity. 
— The deformity in such cases may be in the direction of the 
long axis of the bone resulting in overlapping of the frag- 
ments, in the transverse direction, causing angular displace- 
ment, or by rotation of the distal fragment. 

In all of these forms the displacement may be overcome 
partially or completely by manipulation in the early stages 
of the process when the reparative callus is soft. 

Union with overlapping of the fragments, or with over- 
lapping and rotation of the distal fragment, is necessarily 
accompanied by shortening of the limb. In old cases of 
these forms of deformed union it is not desirable to attempt 
relief by treatment, as the muscles are in such a state of 
permanent contraction as to interfere with any efforts at 
extension of the limb. 

In angular deformity, in the early stages of repair, from 
three to five weeks, the displacement may be removed by 
bending the part over the knee or the edge of a table, and 
the subsequent application of pressure so applied as to main- 
tain the limb in a straight position. In cases in which the 
callus is so firm as to resist efforts of this character, re-frac- 
ture may be accomplished either by perforating the callus 
with a drill, dividing it subcutaneously and partially with an 
Adams saw, or with a chisel, removing a wedge-shaped piece 
of bone, and then applying force to complete the separation 
of the callus. Excision of the callus may be resorted to in 
extreme cases ; but it should not be undertaken without a 



148 



FRACTURES. 



full appreciation of the grave character of the operation, and 
of the possible failure to obtain subsequent osseous union. 

One of the most remarkable cases on record of union 
with deformity is that depicted in Fig. 97, reproduced from 
woodcuts which were made for Mr. Jonathan Hutchinson, 
F.R.C.S. London, of a specimen examined by him in the 
Musee Dupuytren, Paris. The union occurred actually at 
right angles. Fig. 98 exhibits a second specimen from 



Fig. 07. 



Fiff. 98. 





the same source in which the angle is less than in the first, 
but showing still greater deformity. This specimen, as stated 
by Mr. Hutchinson, possesses unusual interest as having 
been deposited in the Museum by M. Malgaigne, a short 
time before his death, and is, perhaps, "one of the last 
results of that surojeon's unwearied zeal for science." 



FRACTUKES. 149 

Ununited Fracture, or Pseudo-arthrosis Non- 
union of a fracture may occur as the result of constitutional and 
local causes. The former includes such conditions as have a 
tendency to diminish the vital powers, as hemorrhage, shock, 
age, and diathesis. Tlie local causes relate to the presence 
of some foreign body, as a piece of necrosed bone, between 
the fragments, or tlie failure to obtain the necessary immo- 
bility of the parts, either by the improper application of 
dressings, the absence of co-operation on the part of the 
patient, or his interference with the dressings. Non-union 
after fracture occurs in the large bones of the skeleton, and 
most frequently in the femur and humerus. Its existence 
may be established if mobility is present between the frag- 
ments six to eight weeks after the period when consolidation 
should have taken place. In non-union the ends of the 
fragments undergo various changes ; they may become 
rounded or conical, and be separated by a distinct interval, 
or the ends may be united by bands of fibrous tissue, which 
inclose them in a capsule, in some instances the interior of 
the sac being lined by a membrane which secretes a fluid 
analogous to the synovia. Again, one extremity may be 
rounded and the other present a cavity into which the for- 
mer rests, forming a joint which resembles the ball-and- 
socket variety. 

In the treatment of delayed union attention should be 
paid to the constitutional as well as to the local conditions 
which are present. Remedies which will invigorate the 
system and contribute to bone production should be admin- 
istered, such as the tincture of the chloride of iron and pre- 
parations of the phosphates. Complete immobilization of 
the fragments should be secured by plaster dressings which 
will permit the patient, at the same time, to obtain the benefit 

13* 



150 FRACTURES. 

of exercise in the open air. By these means, the formation 
of the false joint may be averted, and the union, although 
delayed, may be complete. 

Various plans of treatment have, from time to time, been 
suggested and put into practice to obtain osseous union after 
the establishment of the false joint. Among these are fric- 
tion ; the production of irritation, both external and internal ; 
the use of the seton ; union of tlie fragments by means of 
pegs and wire after the drilling of the fragments ; application 
of caustics and actual cautery to the ends of the fragments ; 
and, finally, resection and approximation of the ends. 

Friction is accomplished by rubbing the ends of the frag- 
ments forcibly against one another, and placing the limb in 
immovable dressings so as to obtain perfect rest. This ma- 
nipulation may be repeated if necessary. An apparatus has 
been devised by Prof. H. H. Smith, which maintains con- 
tinuous friction between the ends of the fragments and per- 
mits the patient to walk 

Irritation over the seat of fracture has been practised, 
using,, for this purpose, blisters and caustic potash. 

Internal irritation may be accompanied by the injection, 
through a canula, of tincture of iodine, nitric acid, or solu- 
tions of nitrate of silver. Acupuncture needles have been 
introduced between the fragments to produce irritation, and 
to these have been attached the poles of a battery. Scarifi- 
cation of the ends has been performed by tenotomes intro- 
duced subcutaneously. 

The seton may be used with advantage in pseudo-arthrosis 
occurring in certain bones. It should be carried near to the 
seat of fracture, or between the fragments, and should remain 
sufficient time only to excite irritation ; the production of 
prolonged suppuration should be avoided — fatal results have 



FRACTURKS. 151 

attended its use in ununited fractures of the femur ; care 
should be taken to avoid large bloodvessels and nerves in 
the passage of the needle. 

Drilling the fragments and fixation by the introduction 
of pegs and screws. Various forms of pins and screws have 
been employed to accomplish union by this method. Dieffen- 
bach introduced ivory pegs, after drilling a number of holes 
into the fragments, and then held them together. Steel rods, 
with gimlet points and with threads cut upon the shaft, have 
been passed through the fragments and allowed to remain 
in position until union has been accomplished. 

Resection of the fragments has been performed, and the 
sawn ends brought into apposition, and so maintained by 
appropriate means. In some instances, the ends have been 
drilled, and wire sutures introduced, so as to hold the frag- 
ments moj-e securely in apposition. 

Exposure of the ends of the fragments, and the applica- 
tion of nitric acid, caustic potash, and the actual cautery have 
been practised in some cases. 

Of these different methods of treatment the use of the 
seton and resection of the fraojments have, accordinor to the 
tables prepared by the late Dr. George Norris, of Philadel- 
phia, accomplished the best results, although fatal results 
have occurred in some of the cases treated by these methods. 
The plan of producing friction by rubbing the ends of the 
fragments forcibly together has also achieved very favorable 
results — without the occurrence of deaths. Cases in which 
this plan failed were treated subsequently by resection and 
the seton with success. Varied results have attended the 
employment of the other plans of treatment ; in some in- 
stances, successful results have followed ; in others, failures; 
and in still others, death has occurred. The general intro- 



152 



FRACTURES. 



duction and use of antiseptic methods of wound treatment 
will, Prof. Agnew states as his belief, disarm resection of its 
danger, and lead to its practice with good results. 

SPECIAL FRACTURES SKULL. 

Cranium. — Fractures of the cranium may occur on the 
vault or at the base, and may be simple, compound, or com- 
plicated. They may be also classified with regard to the 
degree of penetration into complete and incomplete, in the 
former both tables of the bone being fractured, and in the 
latter but one — either the external or internal. 

Causes The causes of fracture are force applied directly, 

producing fracture either on the vault or at the base, such as 

Fiff. 99. 




blows with a bludgeon, axe, or sabre, falls upon the head, or 
gunshot wounds. Figure 99, an illustration of a specimen 



FRACTURES. 153 

in my possession, exhibits the results of blows with the 
pole of an axe, involving on the right side the temporal, 
frontal, parietal, and occipital bones, with almost entire 
destruction of the temporal and sphenoid, with the basilar 
process of the occipital at the base. On the left side a 
blow over the frontal bone just above the supra-orbital 
arch has produced a fracture which extends upward to the 
fronto- parietal suture and downward through the orbit into 
the superior maxillary, palate bones, and pterygoid pro- 
cess of the sphenoid. Over the squamous portion of the left 
temporal there is a short line of fracture, and over the left 
side of the occipital bone there is an opening made by the 
cutting edge of the axe, chipping out a portion of both tables. 
The subject in whom these extensive fractures were re- 
ceived was a young woman who, while asleep, was murdered 
by her paramour. 

Blows upon the cranium may produce fracture of the in- 
ternal table without injury to the external, forming in this 
way an incomplete fracture. 

Repair of fracture of the cranial bones takes place by the 
formation of an intermediate fibrous tissue which may 
undergo ossification. 

Symptoms The symptoms in cranial fractures relate 

rather to the brain than to the conditions of the bone. In 
simple fractures there are usually no symptoms indicating 
the nature of the injury. In fractures complicated with 
depression of the fragments, the symptoms of cerebral com- 
pression may be present if the depression of the fragments 
is sufficient to exert pressure. Cerebral concussion may 
follow in both simple and complicated fractures as the result 
of the force applied in producing the fracture. Hemor- 
Fhage from the nose, intra-orbital ecchymosis, and bloody 



154 FRACTURES. 

and watery discharges from the ear, are symptoms which 
attend fracture of the base of the cranium. 

Diagnosis — In simple fractures the diagnosis is difficult ; 
no symptoms, as a rule, being present by means of which 
the diagnosis may be positively made. It may, in some 
instances, be possible to trace the line of fracture beneath 
the overlying tissues. Often the depression in the soft 
tissues leads to error in diagnosis; the depression being re- 
garded as in the bone substance. 

In compound fractures the wound can be inspected, and, if 
necessary, explored carefully witli the finger in order to ascer- 
tain its condition. Fractures of the base of the cranium may 
be suspected if grave cerebral symptoms are present without 
other evidence of injury to account for them. Intra-orbital 
ecchymosis and hemorrhage from the nose and ear with the 
escape of watery discharges may indicate the existence of 
basal fracture, but these symptoms cannot be regarded as 
pathognomonic, since they may be the result of lesions of 
bloodvessels in these organs, or of the escape of the normal 
fluids of these cavities. 

Prognosis The extent of the injury inflicted upon the 

brain and its envelopes has an important bearing upon the 
prognosis in cranial fractures. The bone injury under ordi- 
nary circumstances is readily repaired with little or no con- 
stitutional impression. In cases of extensive bone destruction, 
followed by necrosis, requiring the removal of large pieces, 
excellent recoveries occur as long as the brain is unimpaired. 

Treatment. — In fractures of the cranial bones, whether 
simple, compound, or complicated, the treatment relates 
largely to the condition of the brain, and constitutional 
remedies are of supreme importance, whilst the local dress- 
ings are of the simplest character, partaking rather more of 



FKACTUKKS. 155 

the nature of wound dressing of the soft parts, than tliose 
which are intended, in any way, to assist in bone repair. 
Fractures of the bones, or those parts of bones which enter 
into the formation of tlie base of tlie cranium, cannot, by 
reason of their position, have dressings applied. 

In simple fractures the head should be elevated, the hair 
removed if necessary, and cold applications made by means 
of the rubber ice-cap or bladders containing crushed ice. 
The constitutional remedies should be directed toward the 
prevention of inflammation of the brain. 

In compound fractures, if depression of the fragments 
exists, elevation and removal by the trephine and elevator 
should be accomplished, and great care should be taken to 
avoid closing the wound of the soft parts too tightly so as to 
prevent free escape of fluids. The local dressings should 
consist of compresses wrung out of cold water until the 
cranial opening is closed, and then such application as will 
stimulate granulation and cicatrization. Antiseptic dress- 
ings may be used with great advantage in certain cases, care 
being taken to afford escape of fluids by means of drainage 
tubes if necessary. 

FACE. 

Nasal Bones. Causes. — Direct violence applied in front 
or on the side — as blows with the fist or bludgeon — produc- 
ing a separation either in the transverse, oblique, or longi- 
tudinal direction, and usually about the middle of the bone. 

Symptoms As more or less displacement attends frac- 
ture of the nasal bone, deformity becomes a prominent symp- 
tom. Mobility can be detected and by manipulation crepi- 
tus may be elicited. Epistaxis and swelling are present. 

Diagnosis. — The diagnosis is made by careful examina- 



156 FRACTURES. 

tioii of the parts in order to elicit crepitus and establish the 
existence of mobility. Swelling, deformity, and epistaxis 
may be present without fracture. It is of the utmost im- 
portance to avoid the occurrence of deformity in the treat- 
ment of fracture of these bones, and hence the examination 
should be thorough, placing the patient if necessary under 
the influence of an anaesthetic agent in order to secure 
quietude during the necesssary manipulations. 

Prognosis The prognosis relates to the occurrence of 

deformity which may be avoided by careful reduction of the 
displaced fragments. 

Treatment In simple fracture of the nasal bones, and 

where the nasal bones alone are broken, there is usually little 
or no displacement of the fragments, and the only dressing, if 
any is required, consists in the application of narrow^ strips 
of adhesive plaster, tlie extremities of which are attached to 
the sides of the face and the body moulded over the bones. 

Fracture of the bones complicated with fracture of the 
nasal processes of the superior maxillae, the nasal spine of 
the frontal bone, the perpendicular plate of the ethmoid, or 
the separation of the cartilages from their bony attachments, 
requires careful manipulation with a strong steel probe or 
female catheter introduced into the nostril and counter- 
pressure exerted by the finger applied on the outside, to 
effect adjustment of the fragments. Displacement is pre- 
vented by the introduction of a piece of English gum cathe- 
ter of the proper length, which is packed about with pieces 
of old linen, or with iodoform gauze or cotton-wool. Prof. 
Agnew suggests the use of pieces of sponge shaped to fit the 
nasal cavity and covered with wax. The sponge soon swells 
and exerts pressure in such manner as to prevent displace- 



FRACTURES. 157 

ment. They may be removed after a period of twenty-four 
hours, and if necessary a second introduced. 

Malar Bone. Cause. — External force applied over the 
bone may cause fracture of tlie zygomatic process; if the 
force is very great, it may produce fracture of the body ex- 
tending to adjacent bones, as the superior maxillary. 

Symptoms The symptoms are contusion and swelling, 

pain, with deformity, and in certain cases mobility and 
crepitus. 

Diagnosis The symptoms are usually sufficiently marked 

in severe cases to render the diagnosis easy. Pressure and 
counter-pressure by the index finger of one hand introduced 
into the cavity of the mouth, and that of the other hand 
placed on the outside over the bone, will determine the ex- 
istence of mobility and crepitus. 

Prognosis As far as repair is concerned the prognosis 

is favorable. Unless care is taken to restore the displaced 
fragments to proper position, more or less deformity will 
result. 

Treatment. — Simple fracture of this bone is not accom- 
panied by displacement of the fragments, and no dressings 
save compresses wet with a sorbefacient lotion are demanded. 
Fractures which are the result of great violence, involving 
the bones with which the malar articulates, produce dis- 
placement, which must be corrected by elevation, pressure, 
and counter-pressure, made, if necessary, by introducing the 
finger within the mouth. Gibson's or Rhea Barton's band- 
age (Figs. 45, 46) should be applied so as to secure immo- 
bility of the lower maxilla, and at the same time support the 
fragments. 

Superior Maxillary Bone. Causes Securely fixed 

in position as this bone is, braced behind by the pterygoid 
14 



158 FRACTURES. 

process of the sphenoid bone through the intervention of the 
tuberosity of the palate bone, and above and laterally by 
the temporal through the zygomatic arch and malar bone, it 
requires great violence to produce fracture of it. Fractures 
through the body are the result of force applied directly 
over the parts, as blows with a bludgeon, a brick, a base-ball, 
or crushes between the bumpers of a car. The alveolor pro- 
cess is more readily broken by reason of its exposed position. 
More or less fracture of the walls of the alveoli accompanies 
the efforts at the extraction of teeth; in instances which have 
come under my observation large portions have been de- 
tached by improper manipulation with the extracting forceps. 
Separation of the adjacent maxilla is a rare accident, and 
when it occurs it is the result of such violence as is likely to 
cause a fatal termination. 

Symptoms. — In simple fracture of the body the symptoms 
are not very marked, there is little or no deformity, and 
crepitus cannot usually be obtained. An inspection of the 
cavity of the mouth will detect the line of separation through 
the palatine and alveolar processes. In fractures of the 
alveolar process the seat of fracture can be readily inspected. 

Diagnosis. — The diagnosis is made by an inspection of 
the parts both within and without the cavity of the mouth ; 
mobility and crepitus can be established by grasping the 
fragments when the fracture involves the alveolar process. 

Prognosis. — The tendency to repair after fracture is so 
marked in this bone that the prognosis is extremely favor- 
able. Ordinarily the displacement is so slight that little or 
no deformity follows repair. 

Treatment. — In simple fracture of the body the dressings 
required consist of a bandage which will hold the lower jaw 
firmly against the upper so as to support the broken bone. 



FRAOTUIIKS. 159 

Of the processes displacement after fracture is more liable to 
occur in the alveolar, and appliances must be adapted to 
overcome this. Teeth which are completely dislocated 
should be cleaned and restored to position, and all com- 
minuted fragments with displaced teeth should be moulded 
into position. Retention of the fragments in place is best 
accomplished by means of the interdental splint (Fig. 103) 
and Rhea Barton's bandage, the latter holding the lower jaw 
against the upper so as to afford support. 

Inferior Maxillary Boxe. Causes Blows given 

over the body or ramus may produce fracture of these parts. 
Falls upon the chin may cause fracture of the ramus or the 
condyloid process. Cases of fracture of the body have come 
under my observation, which were produced by efforts at 
extraction of the posterior teeth, especially the last molar 
or wisdom tooth. 

The Site of Fracture may be in the body, ramus, or 
processes, and may be simple, compound, or comminuted in 
character. Owing to the subcutaneous position of the upper 
border of the bone the fracture is most frequently compound 
into the mouth. 

Symptoms In fracture of this bone all of the signs of 

fracture are usually present. Pain and loss of function are 
usually marked with preternatural mobility, deformity, and 
crepitus. Escape of the saliva is also frequently present as 
a symptom. 

Diagnosis Inspection of the cavity of the mouth will 

show the deformity due to the irregularity of the teeth, and 
mobility and crepitus can be ascertained by grasping the frag- 
ments within and without the mouth, and moving them over 
each other. Deformity is not marked in fractures of the ramus, 
owing to its muscular attachments. Pain felt in front of the 



160 



FRACTURKS. 



ear, with crepitus, which can be felt by placing the finger 
over the neck of the condyle, indicates fracture at this point. 

Fracture of the coronoid process rarely occurs. Immo- 
bility of the fibres of the temporal muscle when the jaw is 
depressed would indicate detachment of the process. 

Prognosis In most cases, union occurs without difficulty ; 

in some, it is delayed, and in otliers necrosis interferes to 
prevent it. Slight deformity in the alveolar border is liable 
to follow in certain cases. Where the fracture is commi- 
nuted, great difficulty is sometimes experienced in effecting 
a favorable result. 

Treatment The dressings for fractures of the body con- 
sist in the use of external and internal splints, with rollers 
to retain the jaw in position against the upper. In some 
instances it has been found necessary to employ wire or silk 
ligatures to surround the teeth, and thus hold the fragments 
in apposition. In still other cases, the bone has been drilled 
on opposite sides of the fracture, and wire sutures introduced. 

External splints may be made of gutta-percha, sole leather, 
or binders' board, and so fashioned as to form a cup to re- 



Fig. 100. 



Fig. 101. 




ceive the body of the jaw. Binders' board is well adapted 
to the purpose, and, after being shaped, should be immersed 
in hot water and moulded upon the part (Fig. 100). Care 
should be taken to pad the splint well with cotton-w^ool or 



FRACTURES. 



161 



lint, so as to prevent excoriations and pain by undue pres- 
sure. The splint may be held in position by Gibson's, Bar- 
ton's, or the four-tailed bandage. During the first week of 
treatment by this plan, the bandage, with the splint, should 
be removed every other day, in order that the external parts 
may be inspected, the fragments being, meanwhile, supported 
carefully by the hand. 

Prof. Hamilton has devised an apparatus, which, in his 
experience, overcomes the disadvantages which follow: the 
application of the external 
splint confined in place by ^** 

the roller. It consists of a 
maxillary strap or band 
made of leather, and two 
counter straps — the occipi- 
to-frontal and vertical, made 
of strong linen webbing. 
The maxillary band is nar- 
row under the chin, broader 
upon the sides of the jaw, 
and has a band of linen 
passing across the front of 
the chin to prevent it from 
sliding backwards. A pad 
must be placed beneath each 
buckle (Fig. 102). 

Internal, or inter-dental 
splints, afford the best means of treating fractures of the 
body of the jaw. They may be made of metal, gutta-percha, 
or vulcanized rubber — preferably the latter — and in order 
that they should be adapted accurately to the parts, it is ne- 
cessary that an impression of the mouth should be taken 

14* 




1G2 



FRACTURES. 



with the fragments accurately adjusted. This impression 
should, if possible, be taken in plaster of Paris, and to do 
tliis properly, the services of a dentist should be invoked, 
who has all the appliances at hand, and is familiar with their 
manipulation. The splint, when applied, embraces the teeth 
of the upper and lower jaws, and extends some distatice over 
the alveolar processes, so as to maintain the fragments in 
accurate apposition. An opening is left between the plates 
for the introduction of a glass tube for the purpose of taking 
liquid nourishment (Fig. 103). Perforations opening into 
the cavities of the splint should be made so as to permit the 
injections of cleansing fluids. This splint is lield in posi- 



Fig. 103. 



Fig. 104. 





tion by turns of the Gibson or Barton bandage. For the 
treatment of fractures of the bone occurring in edentulous 
persons, or where the teeth have been lost, Dr. Guernsey, a 
dentist of New York, has adapted steel branches to the 
interdental splint — a superior, which passes along the upper 



FRACTURES. 1G3 

part of the face, anil an inferior, along the lower jaw ; bands 
are employed to hold the splint in place — one passing under 
the cliin, and one to tlie nape of the neck from the lower 
branch, and one secured to the borders of a cap which is 
worn over the head (Fig. 104). 

Caps of soft metal may be fitted over the teeth, and serve 
to keep the fragments in apposition. 

A mass of gutta-percha may be softened by immersion in 
liot water, and an impression made by placing them between 
the teeth, and carefully elevating the lower jaw, the frag- 
ments being previously adjusted. Hardening of the gutta- 
percha takes place in a few minutes, when the splint can be 
removed, fashioned into shape, and reinserted. Bandages 
are to be used to bind the jaws together. 

The employment of silk or metal ligatures around the 
teeth to keep the fragments in place is objectionable, giving 
rise to pain and soreness in the teeth and soft tissues, and 
very frequently failing to accomplish the purpose intended. 

In aggravated cases of displacement, drilling of the bone, 
and the introduction of strong wire sutures, may be neces- 
sary to obtain coaptation, and maintain the fragments in 
position. 

In fractures of the angle, ramus, coronoid or condyloid 
processes, the dressings consist in the application of properly 
adjusted compresses over the parts, and the crossed bandage 
of the angle of the jaw (Fig. 41). 

In fractures of either tlie upper or lower jaw, the dress- 
ings should be continued from five to six or seven weeks, 
and the mastication of hard substances should be avoided 
for some time after their removal. 

Lachrymal, Inferior Turbinated, Vomer, and Pal- 
ate Bones Fracture of these bones occurs, as a rule, as a 



164 FRACTURES. 

complication with the fracture of adjacent bones, and re- 
quires no special description. 

TRUNK. 

Hyoid Bone. Causes Constriction of the neck with a 

cord, or grasping the neck w^ith the hand with violence, as 
well as blows over the site of the bone, may cause fracture. 
Muscular contraction lias also been assigned as a cause by 
Dr. Hamilton, of New York, who has recorded a case in 
which it occurred 

The seat of fracture may be in the body or cornua — in the 
former as the result of constriction by the cord as in hanging 
— and in the cornua by the forcible grasp of the hand. 

Symptoms. — The symptoms of fracture of this bone are 
almost entirely rational in character. Great pain attends 
all movement of the parts attached to the bone, and as a 
i-esult there is marked loss of function in so far as relates to 
speaking, deglutition, or opening of the mouth. Preter- 
natural mobility, deformity, and crepitus are not usualljj^ 
present. 

Diagnosis — The impairment of articulation, deglutition, 
and movement of the lower jaw should direct attention to a 
possible fracture of the hyoid bone if occurring after any 
injury which would cause constriction of the neck over the 
site of the bone. Crepitus may be detected by the patient 
during efforts at swallowing, or it may be felt, as well as 
the displacement, by the surgeon on introducing the fingers 
into the pharynx. 

Prognosis. — The result in fracture of the hyoid bone de- 
pends upon the character of the injury. If the fracture is 
simple, and there has been little contusion of the parts, 
union may take place without complication. On the other 



FRACTURES. 105 

hand, severe contusion of the parts, involving possible injury 
to the hirynx, may result also in necrosis of the detached 
piece, the formation of an abscess, or displacement of one of 
the fragments, endangering the patient's life. 

Treatment The movable character of this bone, accom- 
plished by the attachment of numerous muscles, renders it 
impossible to secure coaptation and fixation of the fragments 
in case of fracture by the application of any dressings. Im- 
mobility can be alone obtained by maintaining the natural 
position of the head in its relation to the neck — neither 
flexion nor extension. For five or six days nourishment 
should be administered by enemata, and talking should be 
rigidly interdicted. 

Cartilages of the Larynx and Trachea. Causes 

The same as in fracture of the hyoid bone. 

The seat of fracture is most frequently in the thyroid car- 
tilage — after this the cricoid. 

Symptoms. — In addition to the symptoms present in frac- 
^YQ of the hyoid bone, there is bloody expectoration, em- 
physema of the neck, with partial or complete aphonia. 
Dyspnoea is al\\ays present as a prominent symptom, and is 
due in the earlier stage either to extravasation of blood or 
to displacement of the fragments. In the later periods it is 
due to inflammatory swelling or submucous infiltration. 
Mobility and crepitus may be present. 

Diagnosis — The diagnosis must be made by a careful 
study of the symptoms. They are usually sufficiently well- 
marked sooner or later to guide to a correct diagnosis. 

Prognosis — The prognosis is exceedingly grave ; the 
danger, both immediate and more remote, which menaces 
the life of the patient is involvement to a fatal degree of the 
respiration through obstruction in the larynx. Of eighty- 



166 FEACTL'RES. 

nine cases reported by Prof. Agnew, in his work on surgery, 
twenty-two recovered and sixty-seven died. 

Treatment. — As in fractures of the hyoid bone, no dress- 
ings can be applied in fractures of these cartilages which 
will in any way control the mobility of the fragments. The 
treatment should be conducted by position, nutritive enemata, 
and remedies to combat inflammation, and, if necessary, the 
prompt employment of laryngotomy or tracheotomy to re- 
lieve dyspnoea, and prevent a fatal termination. 

Vertebrj::. Causes Violence directly or indirectly 

applied may produce fracture of the vertebrce : directly, as 
by the passage of the wheel of a wagon, or a crush between 
a wagon or car and the wall of a building ; indirectly, by 
falls from a height upon the feet or head, or by the fall of 
a mass of earth upon the body producing extreme flexion of 
the column. 

The seat of fracture may be in the body, arch, or pro- 
cesses. 

Symptoms The prominent symptom in fracture of the 

vertebrae is paralysis, and this is due, if it occurs immediately 
after the receipt of the injury, to pressure upon the cord, ex- 
erted by the displaced fragments ; or, if it occurs later, to the 
pressure made upon the cord by a blood-clot, by inflamma- 
tory exudations, or it may be due to softening of the cord. 

The paralysis varies as to its extent in accordance with 
the site of the injury. Fracture with compression of the 
dorso-lumbar portion of the cord produces paraplegia with 
paralysis of the bladder and rectum. In the dorsal and cervi- 
cal regions, fracture with compression of the cord involves 
the important functions of the intestines and respiration by 
producing paralysis of the abdominal walls, muscular walls 
of the intestines, and muscles of respiration. 



FRACTURES. 167 

In fracture of tlie spinous process deformity and crepitus 
may be present witliout paralysis ; displacement is marked 
in fracture of tlie odontoid process of the axis. Pain 
on movement is also experienced in fracture at different 
points. 

Diagnosis Tlie difficulties of diagnosis relate largely to 

the point of fracture in the vertebra and to the region in- 
volved. In fracture of the spinous process the physical signs 
are usually sufficiently distinct to render the diagnosis easy. 
Fractures of tlie body, laminae, articular or transverse pro- 
cesses are more difficult of detection by reason of the deep- 
seated position of these parts and the dangers which attend 
the manipulations necessary to establish the signs of fracture. 
The effects of pressure upon the spinal cord as manifested in 
the different regions and organs of the body supplied by the 
spinal nerves, must guide the surgeon largely in arriving at 
the nature and extent of the injury. The absence of symp- 
toms of pressure of the cord by displaced fragments of the 
vertebroe should not be received as positive evidence of the 
non-existence of fracture, since the latter may exist with 
even some displacement without any or sufficient compression 
to give rise to pressure symptoms. 

Prognosis. — In fractures of the vertebrae the prognosis is, 
as a rule, unfavorable owing to the injury liable to be in- 
flicted upon the spinal cord and the results which follow 
such injuries. 

Treatment — In fractures of the vertebrae, whether of the 
body, arch, or processes, the patient should be placed in the 
recumbent and straight position on a firm mattress, w^ith a 
soft pillow placed beneath the lumbar region, and in case of 
fracture in the cervical region pillows or folds of cloth should 
be placed alongside of the neck to afford lateral support. In 



168 FRACTURES. 

cases in which the injury is accompanied by paralysis of the 
lower extremities, or a loss of sensation in regions of the 
back, the patient should be placed upon a water-bed ; if this 
cannot be obtained the prominent points should rest upon 
air-cushions or rings in order to remove pressure and pre- 
vent the formation of bed-sores. Where the expense of a 
water-bed prevents its use, a cheap and efficient substitute 
can be made in the manner described on page 130. Appli- 
ances to accomplish extension, or dressings to make lateral 
pressure, beyond those mentioned above, should not be 
employed. Careful attention to the bladder and bowels, as 
well as to the general condition of the patient, forms an im- 
portant part of the treatment. 

Sternum. Causes The causes of fracture of the sternum 

are direct and indirect violence. The former includes blows 
upon the part, as the kick of a horse, or the passage of the 
wheel of a wagon. Indirect violence, resulting in fracture, 
may be applied in various ways, as falls from a height upon 
the head, feet, or buttocks. Muscular contraction partici- 
pates, according to the belief of Prof. Agnew, in the produc- 
tion of fracture in these instances, as well as when it results 
in certain cases of parturition and in violent efforts at 
vomiting. 

The seat of fracture may be at any part of the bone, or 
between the ensiform cartilage and the body. 

Symptoms Pain, which is increased by any movements 

of the chest-walls, as in forced respiration or coughing, is a 
prominent symptom. Deformity is sometimes present, and 
crepitus may be heard by placing the ear over the bone during 
forced respiration ; or it can be felt by placing the hand 
over the seat of fracture during chest movements. 

Diagnosis Crepitus, heard or felt, with swelling, dis- 



FRACTURES. 



1G9 



coloration, and pain, is sufficient usually to establish the 
diagnosis of fracture. Deformity cannot be always relied 
upon, owing to the congenital malformations which are so 
frequently present in this bone. 

Prognosis. — In fractures which are not complicated by 
injury of the lungs or heart, the prognosis is favorable. 
"Where these organs are involved serious complications may 
attend the fracture. ^ 

Treatment Reduction having been effected in case of 

displacement of the fragments, by extension of the body 
over a firm cushion or pillow, combined with elevation of 
the upper extremities and depression of the base of the tho- 
rax, a compress should be applied over the seat of fracture 

and the chest surrounded with ^. ,^, 

Fic:- 105. 
spiral turns of a bandage from 

three to four inches wide. The 
turns of the roller should be- 
gin above, and should be ap- 
plied with sufficient firmness 
to limit thoracic respiration. 
A broad band of Canton flan- 
nel bound firmly around the 
chest, and held by a band 
over the neck (Fig. 105), or 
adhesive strips, two inches 

wide, drawn over the compress and extending between the 
angles of the ribs, can be substituted for the spiral bandage. 
Costal Cartilages. Causes. — Violence applied directly 
or indirectly, producing fracture in the transverse direction, 
and either near the sternal or the costal end. The cartilages 
most frequently affected are those of the seventh and eighth 
ribs. Of the cases recorded, the fracture appears to have 
15 




170 FRACTURES. 

occurred in young persons, and not in those of advanced 
age, when ossification is supposed to have taken place. 

Symptoms. — As in iracture of the sternum, pain is a 
marked symptom, and it is increased during forced respira- 
tion. Deformity due to the overlapping of the fragments is 
frequently present, with preternatural mobility and crepitus. 

Diagnosis By manipulation, executing pressure and 

counter-pressure, the unnatural mobility can be distinguished, 
with the crepitus, whi-ch is somewhat indistinct and softer 
than bone-crepitus. It may sometimes be heard and felt, as 
in fracture of the sternum. 

Prognosis. — Owing to the elasticity of the costal carti- 
lages the force required to produce fracture of them is greater 
than that which may cause fracture of the sternum or ribs, 
and hence the liability of involvement of the organs con- 
tained within the chest with the consequent complications 
which may render the prognosis uncertain. Repair after 
fracture usually takes place by bone, although it may be by 
cartilage, as museum specimens have demonstrated. 

Treatment. — In the treatment of fracture of the costal 
cartilages the dressing should be applied in the same manner 
as in fracture of the sternum, a compress over the seat of 
fracture, with adhesive strips applied over it, being sufficient, 
as a rule, to maintain the fragments in position. 

Ribs. Causes The cause which is concerned in the 

production of fracture of these bones is the same as in fracture 
of the sternum and costal cartilage, viz., force directly and in- 
directly applied. Muscular contraction, as in severe fits of 
coughing, or violent muscular effort, may also cause fractures 
of these bones. When the force is applied directly over the 
part, the fracture occurs at the point of contact. Applied in 
the antero-posterior direction the bones yield at or near the 



FRACTURES. 171 

point of greatest convexity. The ribs most liable to sustain 
fracture are those between the third and eighth ; the first 
and second being protected by the projection of tlie clavicle, 
and the eleventh and twelfth escaping by reason of their 
great mobility. 

Symptoms In simple fracture of the ribs the symptoms, 

with the exception of pain, may not be well marked. Covered 
as they are by muscular structures, and held together by 
intervening muscles with strong aponeuroses, displacement 
to any extent is not liable to occur, and hence deformity is 
not present as a prominent symptom. Crepitus may be 
heard by placing the ear over the point of suspected fracture. 

In complicated fractures the symptoms of the injury in- 
flicted upon the overlying or intervening muscular structures 
or the lungs or heart intensify those of fracture of the ribs. 
In these cases haemoptysis, intense pain owing to injury of 
the intercostal nerve, hemorrhage from wounding of the 
intercostal artery, pleurisy, pneumonia, or emphysema re- 
sulting from wounds of the pleura or lung may occur. 

Diagnosis. — The diagnosis, in simple fractures owing to 
the absence of well-defined symptoms, is somewhat obscure. 
Crepitus may be detected by the ear or hand placed over 
the supposed seat of fracture. If overlapping of the frag- 
ments occur the displacement may be felt by passing the 
finger over the seat of fracture. In complicated fractures 
the careful study of the symptoms presented lead to the 
formation of a correct diagnosis. 

Prognosis. — The prognosis is favorable in simple fracture. 
The nature of the complication, with the age and slate of 
health of the individual, render the prognosis very doubtful 
in complicated cases. 

Treatment — The indication to be fulfilled by dressings in 



172 



FKACTUUES. 



¥m. 106. 



fractures of the ribs is to so control the thoracic respiration as 
to secure rest of the broken bones. As displacement is usually 
very slight it is not necessary ordinarily to direct treatment 
to the relief of this condition. The best means of securing 
rest of the broken bone^ as well as to overcome displacement 
if it should exist, is to apply strips of adhesive plaster over 
the side of the chest, two to two and a half inches wide, and 
long enough to reach from the vertebral column to the me- 
dian line of the sternum. Tlie application of these strips 
should begin two or more ribs above that fractured, and 
passing down cover it with the same number below. They 

should be applied parallel to 
the direction of the ribs, and 
one-half of the strip should 
be covered by that succeeding 
so as to present an imbricated 
appearance, and afford firmer 
support. (Fig. 106.) A wide 
bandage, made of Canton flan- 
nel or strong muslin, or the spi- 
ral bandage of the cliest (Fig. 
53), may be employed as in 
fracture of the sternum. In 
cases of bilatei-al fractures a 
plaster jacket may be applied 
with advantage over a thin 
knit flannel shirt, to prevent 
excoriation of the surface. Complicated fractures require 
that treatment should be directed to the conditions which 
accompany the fracture. If the fragments have penetrated 
the lung they should be elevated, and if necessary resection 
should be performed in order to relieve the pressure. 




FRACTURES. 173 



UPPER EXTREMITY. 



Clavicle. Causes The causes which act in the pro- 
duction of fracture are direct and indirect violence, with 
muscular contraction. Direct force may be applied by blows 
with a bludgeon or the recoil of a musket, the butt being 
improperly placed over the bone at the time of firing, pro- 
ducing a transverse separation of the bony fibres. Indirect 
force may be transmitted by falls upon the hand, elbow, or 
shoulder, producing an oblique line of fracture. Fracture, 
as the result of muscular action, occurs, according to reported 
cases, when the arm is in a state of extreme extension. 

Bilateral fracture of the clavicle is extremely rare. In- 
complete fracture of the bone occurs frequently in children 
and young persons. 

Symptoms — Pain, deformity, and crepitus are present as 
symptoms of fracture of this bone. Loss of function is, as a 
rule, very marked, the patient being unable to grasp the 
opposite shoulder, or to make extended movements of the 
extremity; the shoulder is depressed, and the patient sup- 
ports the arm of the affected side. 

Diagnosis. — Crepitus may be elicited by manipulation 
of the shoulder and extremity, after placing the fragments 
in apposition. Carrying the arm upward, outward, and 
backward will accomplish this. Deformity can be seen, and 
the displacement of the fragments felt by passing the finger 
along the border of the bone. The displacement of the arm 
downward, forward, and inward is characteristic of fracture 
of the bone. 

Propiosis In uncomplicated cases the prognosis is 

favorable, union taking place promptly; but, as a rule, with 
more or less shortening and deformity. Wounds of the sub- 

15* 



174 FRACTURES. 

clavian or jugular veins may occur, with paralysis of the 
arm, as the result of pressure of the fragments upon the 
brachial plexus of nerves, in complicated cases. The func- 
tions of the arm are not, as a rule, impaired where union 
takes place with shortening and deformity. 

Treatment In the adaptation of dressings in the treat- 
ment of fractures of this bone, it is important that its func- 
tion as a brace or stay-bone to the shoulder should be kept 
clearly in mind, and further, that the action of the muscles 
which are concerned in displacing the shoulder, and with it 
the upper extremity after fracture should be understood. 
The bones, firmly fixed as they are between the sternum 
and acromium process of the scapula, maintain the separa- 
tion of the shoulders, and in this way contribute largely to 
the use of the upper extremities as prehensile organs. The 
stay being broken, the shoulder, and with it the attached 
upper extremity, falls inward, whilst the muscles which are 
attached to the scapula draw it downward and forward. 
The muscles acting directly upon the scapula in this action 
are the serratus magnus and pectoralis minor, assisted by 
the pectoralis major and latissimus dorsi. The sternal frag- 
ment is displaced by the action of the sterno-cleido-mastoid 
muscle, although the fixed position of this extremity through 
the attachment of the rhomboid ligament and subclavian 
muscle limits very materially the degree of displacements. 
Prof. Agnew has directed attention to the action of the 
rhomboideus major and minor, which, in fracture of the 
bone, rotate the acromial fragment, and thus change its 
position in its relation with the sternal fragment, from an 
anterior to that of one under or posterior. The displace- 
ment of the extremity is therefore downiuard, forivard^ 
inward, with a rotation of the acromial fragment on its axis. 



FRACTURES. 175 

The displacement can be overcome, and tlie fragments re- 
tained in aj^position by carrying tlie shoulder itpward, out- 
ward, and backward, and the dressings should be so applied 
as to accomplish this object, and at the same time keep the 
inferior angle of the scapula /b/'?r«/'flf. 

Application of Dressings in the Recumhent Position — 
According to this method of treatment, the patient is placed 
in bed upon a firm mattress, with the head resting upon a low 
pillow, and the chin slightly depressed. The arm of the 
affected side is flexed so that the hand can grasp the point 
of the opposite shoulder (Velpeau's position). In this posi- 
tion it will be found on examination that the displacement 
is overcome, and that the fragments are in apposition. A 
spiral roller applied around the chest, the turns beginning 
below and carried upward, will assist the patient in main- 
taining this position of the arm. If the patient objects to 
the confinement in bed for the full length of time required 
for union of the fracture (from four to six weeks), he may 
remain for the first week or two, until the reparative pro- 
cess has made sufficient progress to hold the fragments in 
apposition under any of the forms of dressings employed in 
the erect position. Treatment in the recumbent position, 
providing the full cooperation of the patient is obtained, 
affords better results than can be secured by any other 
method. 

Application of Dressings in the Erect Position. — The 
object of the dressings applied in this position is not only to 
overcome the displacement, and maintain the fragments in 
apposition, but to permit the patient to walk about and en- 
gage, to a certain extent, in his business pursuits. Of the 
dressings devised for use according to this method, there 
are a large number, consisting of bandages applied in va- 



176 FRACTURES. 

rious ways, with and without pads in the axillce, slings, pads, 
and rings, adhesive plaster, and plaster of Paris dressings. 

Bandage Dressings. — These consist of the posterior figure- 
of-eight (Fig. 49), Desault's and Velpeau's bandages. Of 
these the posterior figure-of-eight was first employed. Its use 
has been largely discontinued on account of the difficulty ex- 
perienced in preventing pain by pressure of the turns of the 
bandage in the axillge and the production of excoriations, if 
the bandage is applied with sufficient firmness to accomplish 
the purpose of straightening the clavicle. Modifications of 
this form have been made in leather and cloth, the shoulder- 
straps, made of chamois skin or some soft material, being 
stuffiid and fastened to back pieces ; the arm is, in this form, 
suspended in a sling. Dr. E. M. Moore, of Rochester, N. Y., 
has devised a modification of the posterior figure-of-eight 
bandage, which, by enveloping the elbow at the arm of the 
affiscted side, assists in throwing the shoulder outward, and 
at the same time, obtaining elevation of the arm. If band- 
ages of this form are used care should be taken to protect 
the surfaces of the shoulders and axilla) from compression. 

Desaulfs Apparatus. — A? already described (p. 100, Fig. 
67), this apparatus consists of three bandages and a pad; the 
first bandage can be dispensed with by using tapes to hold the 
pad in place, and this will contribute to the comfort of the 
patient by the removal of one covering, an important con- 
sideration in warm weather. This form of dressing fulfils 
the indications present in the treatment of fracture of the 
clavicle, but is liable to become disarranged by the move- 
ments of the patient. This can be obviated to some extent 
by stitching the turns together, or covering the outside with 
a layer of starch or plaster. 



FKACTURES. 



177 



Velpeau^s Bandage The position in which the arm is 

placed in the application of this bandage secures an excellent 
adjustment of the fragments, and the turns of the roller in- 
crease the advantages gained by the position by affording 
complete support. In the use of the bandage care should be 
taken to prevent excoriation of the surface of the chest and 
inner surface of the arm by the intervention of soft com- 
presses (Fig. 60). 

Fox's Ajrparatus. — In 1828, Dr. George Fox, of Phila- 
delphia, devised an apparatus for treatment of fracture of 
clavicle, whicii consists of a sling, a pad, and a ring. To 
the sling tapes are sewed, which secure it to the ring which 
is applied over the shoulder of the sound side ; the pad is 
placed in the axilla of the affected side, and is held by tapes 

Fig. 107. 




which attach it to the ring. This dressing has been em- 
ployed, since its introduction, in the surgical wards of the 
Pennsylvania Hospital with the most successful results, espe- 



178 



FRACTURES. 



cially in fractures of the outer extremity of the bone (Figs. 
107, 108;. 

Fis. 108. 




Modifications of this 
form of dressing have 
been made by Hamilton, 
Levis (Fig. 109), and 
others. 

An efficient dressing, 
according to the experi- 
ence of Prof. Agnevv, 
may be made from a 
piece of strong muslin, 
two yards long and seven 
inches wide, prepared 
as the four-tailed sling, 
with the body twelve 



FKACTUKES. 



179 



inches in length, and in the centre of this an opening to 
receive the point of the elbow. The arm being placed so 
that the hand grasps the opposite shoulder, the point of the 
elbow is placed in the opening ; the lower tails are passed 
over the chest anteriorly and posteriorly and tied together 
over the sound shoulder ; the tail carried across in front of 
the chest should pass beneath the arm. The upper tails 
are passed around the arm and body, and tied on the op- 
posite side. 

Adhesive Plaster Dressing Dr. Sayre, of New York, 

secures the arm in position by means of two bands of adhesive 
plaster, three inches and a half in width, and of such length 
as may be required. One band is applied about the arm of 
the affected side, and then drawn across the back, and made 
to encircle the body (Fig. 110) ; the second band receives the 
point of the elbow in an opening provided for that purpose, 

Fig. 110. 




180 



FRACTURES. 



and the ends are carried across the chest in front and behind, 
and fastened together over the shoulder (Figs. Ill, 112). 



Fi^. m. 




FRACTURES. 



181 



Plaster of Paris Dressings — Tn the Bellevue Hospital, 
New York, a plaster dressing has been introduced which is 
described as being both efficient and comfortable. The arm 
is placed in the Yelpeau position, and secured by alternate 
turns of the roller around the chest and over the forearm 
and hand. The plaster is 

applied over the turns as Fig. 113. 

in the ordinary plaster 
bandage (Fig. 113). 

In the description of the 
diflferent dressings which 
are employed in the treat- 
ment of fracture of the 
clavicle it will be observed 
that they are of three 
general forms. One class 
of the dressings is so ap- 
plied as to act on the 
shoulder, another upon 
the elbow, while a third 
combines action upon both 

shoulder and elbow. Authorities agree that, under any form 
of dressing, union without more or less deformity, with 
accompanying shortening, is of rare occurrence. Efforts 
should always be made to secure the best results. 

Scapula. Causes Fracture of the body is the result 

of force directly applied. The processes, head, and pos- 
sibly the neck, may sustain fracture by indirect violence 
transmitted through the arm. A case is reported in which 
fracture of the neck occurred as the result of muscular con- 
traction, in the effort made by a lady to throw a necklace 
over the head. 
16 




182 FRACTURES. 

Symptoms. — The symptoms varv according to the position 
of the fracture. Pain on movement, with more or less loss 
of function of the arm. is usually present. Deformity accom- 
panies fracture of the more superficial portions of the bone. 
Crepitus can also be detected. 

Diagnosis — In fracture of those parts of the bone which 
can be grasped bv the hand crepitus may be elicited and de- 
formity recognized. In fracture of the neck or processes, 
crepitus may sometimes be felt by grasping the parts and 
executing movements of the arm in various directions. 

Prognosis Slight impairment of function of the arm 

may follow fracture of the scapula when accompanied by 
severe injury of the soft parts, or when the result of gun- 
shot wounds. Union with more or less displacement of the 
fragments occurs in simple fractures of the body. Fibrous 
union occurs, as a rule, after fractures of the acromion or 
coronoid processes. 

Treatment. — The character of the dressings applied in 
fracture of this bone depends upon the seat of the fracture, 
whether it be in the body, neck, acromion, or coracoid pro- 
cesses. 

Body. — In fractures of the body the fragments may be 
kept in apposition by the application of a broad band of 
adhesive plaster carried from the vertebral column across 
the broken bone, being well moulded to its anterior and pos- 
terior bordej'S. and terminating within three to four inches 
of the sternum. The ends of the band should be fastened 
after it has been well adjusted over the scapula. The arm 
should be flexed and placed in tlie sling of Fox's apparatus, 
the elbow elevated by fastening the posterior tapes to the 
ring on the opposite shoulder, and the arm held against the 
body by tlie turns of the spiral bandage. 



^l{A^Tl•KK^^. 183 

Neck, Acromion, and Coracoid Processes. — In fracture 
of these parts of the bone the Iiead of tlie humerus should be 
pushed up so as to act as a support, and it should be held in 
this position by Velpeau's bandage. Fractures of acromion 
process may be treated by confining the patient in bed, and 
carrying the arm directly away from the body, and support- 
ing it upon a pillow. The function of the shoulder-joint is 
liable to become impaired by the disuse to which it is sub- 
jected in the treatment, as well as its involvement in frac- 
tures of the neck and glenoid cavity, and it is therefore im- 
portant that passive motion should be instituted at the end 
of the fourth week. 

Humerus — Fractures of this bone may occur in the 
upper extremity, the shaft, and the lower extremity. Those 
of the upper extremity are divided into fractures within the 
capsule (intra-capsular) and those without (extra-capsular). 

Intra-capsulak Fractures. Causes Fractures wnthin 

the capsule are generally the result of gunshot injuries, pro- 
ducing those which are compound in character. Direct 
violence, as in a railroad crush, may cause a comminuted 
fracture of the head of the bone, or fracture through the 
anatomical neck. 

Symptoms — In compound fractures the symptoms are 
sufficiently plain, whilst in simple fractures they may be very 
obscure. Pain, with loss of function, is usually present ; 
crepitus is not well marked, and deformity is absent, except 
in cases of impaction, in which there may be flattening of 
the shoulder, with projection of the acromion process. 

Diagnosis — In compound fractures the joints can be ex- 
plored with the finger, and the fracture detected. In some 
cases of simple fracture the head of the bone may be seized 
and crepitus elicited by rotating the shaft. Impacted frac 



184 FRACTUllES. 

tures may be recognized by pressing the finger into the joint 
from the axilla, and in this way detecting the shortened 
head. 

Prognosis Osseous union does not occur after intra- 
capsular fracture. When fragments are detached in com- 
pound fractures, necrosis and suppuration may ensue, and 
they may be discharged. Fibrous union may follow incom- 
plete separation through the anatomical neck. When the 
separation is complete the head of the bone loses its vitality 
and disappears by a process of absorption. The late Prof. 
Gross records a case in his System of Surgery in which the 
" head of the bone, united by a thick layer of osseous matter, 
is turned upside down." 

Treatment In intra-capsular fractures the dressings should 

consist of a shoulder-cap extending to witiiin three inches 
above the elbow, and a broad roller which secures the arm 
to the side of the body. The arm should be fiexed, and the 
hand drawn across the chest and supported in a sling. The 
shoulder-cap can be found in the shops, made of felt or other 
substance (Fig. 114). An excellent substitute can be made 

Fiff. 114. 




from a piece of binder's board of suitable width and length, the 
edges of the upper end of which should be incised, in order that 
it may be more readily moulded to the shoulder, after having 
been immersed in hot water. Before application it should 
be well padded with layers of soft material or cotton-wool. 
Fracture through the anatomical neck is best treated by 



FRACTURKS. 18o 

the introduction of a smjill, wedge-shaped pad in the axilla 
with the shoulder-cap, and the application of Velpeau's 
bandage, so as to support the shaft against the head of the 
bone, and secure the dressings in position. 

ExTRA-CAPSULAR FRACTURES In this class may be 

included fractures occurring between the anatomical neck 
and insertion of the latissiraus dorsi and teres major muscle. 

Causes. — The causes concerned in their production are 
external violence directly applied, the arm being held near 
the body, and resulting in fracture of the great tuberosity, 
through the epiphysis, or surgical neck. 

Symptoms. — The symptoms vary with the nature of the 
fracture. In all, pain and impaired function are more or 
less distinctly marked. In fracture of the great tuberosity 
and through the epiphysis the shape of the shoulder is altered, 
increased in breadth, with undue prominence of acromion 
process in the former ; in the latter, the rotundity of the 
shoulder is not removed, but a prominence due to the upper 
end of the lower fragment exists just above the coracoid pro- 
cess. In fractures through the surgical neck the usual signs 
of fracture are present — pain, loss of function, shortening, 
preternatural mobility, and crepitus. 

Diagnosis As a rule, the detection of fractures in this 

region is difficult, owing to the absence, in some, of the marked 
symptoms of fracture ; and in others, to the obscurity which 
attends them by reason of the swelling which is liable to 
occur soon after the receipt of the injury. The differentia- 
tion between fractures occurring at this point and dislocation 
at the shoulder-joint is always to be considered. Crepitus is 
indistinct, and difficult to elicit in fractures through the 
epiphysis and greater tuberosity — more easily obtained in 
fractures of the surgical neck. As a rule, the displacement 

10^ 



186 FRACTURES. 

of the fragments is not very great, unless the injury has fol- 
lowed the application of great force. The diagnosis is still 
more difficult if impaction has occurred. Its presence may 
be suspected if the arm is shortened and its function im- 
paired with the absence of the marked signs of luxation. 
Extensive manipulation should not be resorted to in these 
cases, lest the impaction may be disturbed. 

Prognosis Favorable as to union in all, with but slight, 

if any, impairment of function; fibrous union is liable to 
occur after fracture of the great tuberosity, owing to the 
difficulty of securing and maintaining accurate approxima- 
tion of the fragments. 

Treatment In all extra-capsular fractures, including those 

of the great tuberosity, separation of the epiphysis alone, or 
with the head and tuberosities, and those of the surgical neck, 
the best form of dressing consists in the application of the 
shoulder-cap, which should envelop the outer, anterior, and 
posterior surfaces of the arm, and extend below to a point 
above the condyles, with a short internal splint ; or, as Pi-of, 
Agnew prefers, the3 internal angular splint reaching to the 
end of the fingers. He also advises the use of the primary 
roller, which should extend from the hand to the shoulder. 
The internal angular splint is carefully padded and placed on 
the inside of the arm, the upper extremity being covered by 
a mass of cotton-wool, and carried well up into tlie axilla. 
The shoulder-cap — lined with cotton-wool or a soft compress, 
turning over the upper and lower edges, so as to remove 
pressure at these points — is placed in position, and a second 
roller is applied over both splints, beginning at the hand and 
terminating at the shoulder, by a few turns of the s[)ica ban- 
dage of the shoulder. The hand and wrist are supported in 
a sling, and the arm is confined to the side of the body by 



FKACTLRES. 



187 



spiral turns of a roller, or a single strip of muslin may be 
employed in its place, with the advantage of greater comfort 
to the patient (Fig. 115). The internal angular splint may 



Fiff. 115. 




be dispensed with in the treatment of these fractures, the 
side of the body affording, when the arm is flexed and held 
against it by turns of the roller, sufficient support to prevent 
displacement. 

Compound fractures of the upper extremity should be 
dressed in the same manner as those which are simple, pre- 
cautions being taken to provide a free escape for inflamma- 
tory products, should they form. In compound and com- 
minuted fractures involving the shoulder-joint the expediency 
of practising excision should always be considered. 

Shaft. Causes. — Force applied directly is the cause of 
most fractures occurring in the shaft of this bone. Many 



188 FRACTURES. 

instances are recorded in which muscular contraction has 
produced fracture. In some of these but slight effort had 
been made. 

Symptoms The symptoms are usually well marked, and 

are those of fractures in general. 

Diagnosis. — Owing to the marked character of the symp- 
toms the diagnosis is not difficult. Deformity, preternatural 
mobility, and crepitus are present, and can be recognized. 
The direction of the displacement of the fragments depends 
upon the relation which the seat of fracture has to the mus- 
cular attachments. The action of the deltoid muscle is 
especially marked in the production of displacement when 
the fracture occurs just above or below its point of insertion. 
The biceps and triceps muscles exert a decided action on 
the lower fragment in fracture through the lower third. 

Prognosis. — While in simple fractures the prognosis may 
be stated as always favorable, yet there are frequently con- 
ditions which arise in connection with fractures of the shaft 
which complicate the results in a marked degree. Among 
these may be enumerated deformity, stiffness of the elbow- 
joint, false-joint, paralysis of the extensor and supinator 
muscles of the forearm, owing to injury inflicted upon the 
musculo-spiral nerve, and finally extensive sloughing, as the 
result of compression of the brachial artery by the fragments. 

Treatment Adjustment of the fragments having been 

obtained by extension, counter-extension, and manipulation, a 
roller is carried from the hand to the shoulder, and an internal 
angular splint, having an obtuse angle, and of sufficient length 
to extend from the axilla to the ends of the fingers, is applied to 
the inner surface of the arm, which is flexed at the proper angle, 
and the shoulder-cap is placed in position. A second roller is 
now applied, extending from the hand to the shoulder, terminat- 



FRACTURES, 



180 



ing in the spica bandage of shoulder, fixing the splints firmly 
in position. In place of the shoulder-cap splint three short 
splints may be substituted (Fig. 116); the longest one is 
applied to the outer surface, the next in length to the pos- 



Fis. 116. 



y 




terior, and the shortest to the anterior surface. The arm is 
to be suspended in a sling. 

Lower Extremity. — Fractures of the lower extremity 
embrace those above the condyles, supra-condyloid and 
those of the condyles, condyloid. 

SuPRA-coNDYLOiD FRACTURES. Cciuse — Forcc applied 
directly to the lower extremity of the bone or transmitted 
by falls upon tlie hand. 

Symptoms. — The symptoms are usually well marked in 
fracture at this point — deformity with shortening, unnatural 
mobility, and crepitus. The deformity is produced by the 
overlapping of the fragments, the lower end of the upper 
fragment projecting anteriorly, just above the bend of the 
elbow. The mobilitv is much exaggerated, and not limited 



190 FUACTURES. 

to the normal hinge-joint movement — flexion and exten- 
sion. Crepitus can be felt by grasping the parts firmly. 

Diagnosis — The diagnosis is to be made between fracture 
at this point and luxation of the elbow-joint. The principal 
signs of fracture are the shortening of the arm, the position 
of the olecranon process and condyles in the same line, the 
presence of crepitus, the great mobility of the forearm, and 
the ease with which reduction is effected and the recurrence 
of the displacement, if means of retention are not employed. 
In luxation the length of the arm is normal, the olecranon 
process is above the line of the condyles, crepitus is absent, 
the forearm is fixed in its abnormal position, and reduction, 
which is more difficult to effect, is permanent. 

Prognosis The prognosis is favorable as to the occur- 
rence of union, but unfavorable in a large majority of cases 
as to the complete restoration of the function of the elbow- 
joint. In adults, it is possible sometimes to secure their 
co-operation in the persistent efforts which must be made to 
overcome the stiffening, and in some cases firm anchylosis of 
the joint. In children, however, who do not appreciate the 
value of the full function of the joint, the task is very diffi- 
cult, and in most cases impossible to be performed. Efforts 
should be always made under the influence of an anaesthetic 
agent to break up the adhesions which may exist, and to 
exercise the joint, in the hopes of obtaining their removal 
by absorption, and at least a partial restoration of the func- 
tions of the joint. 

Treatment The dressings in these fractures consist of 

two rollers, two splints, anterior (Fig. 117), and a posterior 
angular splint, and a sling to suspend the arm. The best 
form of the anterior angular splint is that which has a joint 
which can easily change the angle without disturbing the 



FRACTURES. 



191 



dressings, and the screw of wliieli does not interfere witli the 
application of the roller. That devised by Prof. Agnew is 



Fig. 117. 





moved by a racket-hinge, which accomplishes the object in 
an excellent manner (Fig. 118). The posterior splint is 



Fig. 118. 




arranged in the shape of a trough. It may be made of 
binders' board, leather, or any other material which can be 
moulded easily to the part, and should extend from the mid- 
dle of the arm to the middle of the forearm (Fig. 119), and 
should be deep enough to encircle one-half of the circumfer- 
ence of the arm. The late Prof. Gross employed a trough 
made of tin. Reduction having been effected, the primary 



192 



FRACTURES. 



roller is applied, as in fracture of the shaft, and the anterior 
splint, extending from the shoulder to the hand, is well 
padded and placed over the anterior surface, while the pos- 
terior splint, also well padded, is applied to the posterior 




surface. These are held in position by the second roller, 
which is now applied, and the hand suspended in the sling. 
Passive motion should be carefully instituted, at the end of 
the second week, in order to overcome any tendency to 
anchylosis which might arise, and should be continued at 
such intervals as may be deemed necessary. 

Condyloid Fractures — These include those through 
the base — between the condyles — through the base and be- 
tween the condyles, a combination of the two — of either 
external or internal condyle and separation of the epicondyle 
from internal condyle. 

Causes Fractures of this part of the lower extremity of 

the humerus are, as a rule, the result of external violence, 
as blows or falls upon the point of the elbow, the arm being 
flexed. Indirect force transmitted through the forearm 
by falls on the hand may be an exciting cause. Muscular 
contraction has been observed to be a cause in epicondyloid 
separations, especially in young subjects. 

Symptoms Pain on movement of the joint ; rapid swell- 
ing ; marked increase in breadth of the elbow ; deformity 



FRACTUliKS. 193 

more or less prominent according to the seat of fracture ; 
preternatural mobility ; dislocation of the bones of the fore- 
arm in certain forms ; crepitus more or less distinct. 

Diagnosis. — Fractures involving the condyles are to be 
diagnostic^ited mainly by the disturbed relations of these 
prominences to the fixed points of the surrounding structures, 
and to each other. They are also to be distinguished from 
dislocation by differentiating the symptoms of each condition. 

Prognosis In all fractures of the lower extremity, 

whether directly or indirectly involving the elbow-joint, the 
prognosis as to the future function of the joint is unfavor- 
able, as anchylosis, with more or less stiffening, is certain to 
supervene. These conditions may be partially overcome by 
appropriate and long-continued treatment. 

Treatment. — When it is possible for the surgeon to keep 
the patient under strict observation it would be proper to 
institute treatment for the purpose of allaying the inflamma- 
tory conditions which, as a rule, attend fractures of this 
region. This treatment should consist in the application of 
leeches, or the use of sorbefacient lotions, as laudanum and 
lead-water. During this preliminary treatment, all splints 
and other permanent fracture dressings may be omitted, 
the arm being supported on a pillow. It is regarded safer, 
however, to reduce the fracture, and at once apply the dress- 
ings, the lotions being applied if necessary over them. The 
primary roller should be applied to the arm in a flexed 
position, and the anterior angular splint, arranged at an 
obtuse angle, should be placed in position, a pledget of 
cotton-wool being interposed between the inner surface of 
the joint and the splint. A second roller is now applied to 
retain the splint in position. If there exists a tendency to 
posterior displacement of the fragments and bones involved, 
17 



194 



FRACTURES. 



it is desirable to apply the posterior angular splint or trough 
as'in supra-condyloid fractures (Fig. 120). Passive motion 
should be commenced, as soon as the inflammation subsides, 
by changing the angle of the anterior splint. More decided 

Ficr. 120. 




movement should be practised at the end of the second week, 
and this is best accomplished after the removal of the dress- 
ings; this being done, the elbow should be grasped, the point 
resting in the palm of the hand, and the thumb and fingers 
embracing and supporting the condyles, while extension and 
flexion are cautiously made. This manipulation must be per- 



FRACTURKS. 19o 

formed every second or tliird day until the expiration of the 
fourth week, when all dressing may be removed and tlie 
arm supported in a sling. Tiie patient should be instructed 
to practise daily the various movements of flexion, extension, 
supination, and pronation, and continue the exercise until 
the function of the joint is restored. 

When fibrous adhesions form, as the result of the inflam- 
matory complication, producing anchylosis, the patient 
should be placed under tlie influence of an anaesthetic agent 
and the bands broken by forcible extension and flexion, and 
motion should be accomplished by repeating this manipula- 
tion as may be deemed advisable. If the anchylosis is bony 
in character, or due to osseous union of a displaced fragment, 
the question of refracture and non-interference is to be con- 
sidered. If in the progress of a case anchylosis is found to 
be inevitable, the arm should be placed at such angle as to 
permit access to the mouth, and should be allowed to remain 
in this position. 

Compound and comminuted fractures of the elbow-joints 
are the result of injuries received in machinery or crushing 
under the wheels of a wagon or car. They are recognized 
by careful inspection and manipulation ; the index finger, 
after being washed in an antiseptic solution, may be intro- 
duced for the purpose of exploring the wound. The prog- 
nosis is always of an unfavorable character, the joint, if 
preserved, being deprived, to a greater or less extent, of its 
function. In some cases excision or amputation may be 
demanded. An effort should always be made to save the 
limb if possible. If by the employment of such local appli- 
cations as will overcome the inflammatory conditions, ampu- 
tation is required, it may be performed at a later period if 
necessary after suppurative action has been established. 



196 IR.VCTUUES. 

Forearm — The bones of the forearm — radius and ulna — 
may sustain fracture conjointly or separately. The seat of 
fracture of both bones is most frequently at or a short dis- 
tance below the middle. Of the separate bones, the radius 
is fractured more frequently than the ulna, and iti the lower 
third more frequently than in the upper third or middle. 
Fracture of the radius may occur in the neck, below the 
tuberosity, in the middle of the shaft, or in the lower ex- 
tremity. Those of the lower extremity present a number 
of varieties : the line of separation may be one which is 
transverse, and situated from one inch to one inch and 
a half above the articulating surface, and may be accom- 
panied by a fracture of the styloid process of the ulna. A 
second variety is that in which the fracture involves the 
joint, the styloid process being detached by an oblique line 
of separation. A third variety, that which is known in this 
country as Ehea Barton's fracture, consists in a fracture of 
the posterior portion of the articulating surface, the line of 
fracture being obliquely upward', and terminating three- 
quarters of an inch above. Modifications of this form may 
occur in which the portion of bone separated from the pos- 
terior surface is comminuted, and may be accompanied by a 
transverse fracture of the bone. Fractures of the ulna occur 
through the olecranon and coronoid processes, upper and lower 
third, and in the middle ; that through the olecranon process 
is most frequent ; fracture of the coronoid process is rare. 

Causes. — Fractures of the bones of the forearm may be 
the result of force applied directly or indirectly, or of mus- 
cular contraction. That of both bones or of either bone at 
the middle is caused usually by force directly applied, as the 
passage of a wagon-wheel or a blow from a bludgeon. Frac- 
ture of the olecranon process of the ulna follows the applica- 



FRACTURES. 197 

•tion of sufficient force directly over the parts, as happens in 
falls upon the elbow, the arm being flexed. Fracture of the 
lower end of the radius is caused by I'alls upon the hand, either 
in a state of extension or flexion — most frequently in the first 
— the force being applied indirectly, and transmitted through 
the carpus to tlie end of the bone. I have met with two in- 
stances in which a bilateral fracture (Barton's variety) occurred 
in elderly females : in one the cause was a fall upon the pave- 
ment with both bones extended in the effort to prevent the 
fall ; the other in a lady eighty years of age, and was the 
result of a fall down a flight of stairs ; in this case there was 
associated with the fracture of the left radius a comminution 
of the end of the ulna. 

Fracture of both Bones. Symptoms The symp- 
toms are usually w^ell marked : pain is felt on movement, 
and crepitus can be readily elicited ; preternatural mobility 
with deformity is also present. In some instances the defor- 
mity is not very great, while in those of the green-stick 
variety, occurring in children, it is most marked, and ex- 
tremely difficult to overcome. 

Diagnosis The diagnosis in fractures of the bones is not 

difficult, owing to the well-marked character of the symp- 
toms. In fractures at the lower extremity the deformity 
may resemble that which is present in luxation at the wrist- 
joint. The existence of crepitus will establish the nature of 
the injury. 

Prognosis — More or less impairment of the functions of 
supination and pronation is liable to occur in these fractures, 
owing to the encroachments upon the interosseous space by 
redundant callus or the approximation of the ends of the 
fragments. As a rule, union takes place readily. 

Treatment — In the treatment of fractui-e of both bones of 
17* 



198 FRACTURES. 

the forearm it is of the utmost importance that the limb 
should be placed in such position as to preserve the interos- 
seous space and parallelism of the bones. TVhen the fracture 
occurs in the upper third these conditions are best main- 
tained bj applying the dressings with the forearm in the 
supine position ; for fractures in the middle or lower third, 
the position should be that midway between supination and 
pronation, the thumb directed upwards. It is also important 
that the dressings should be applied with the arm in the 
Jiexed position in order to avoid undue pressure upon the 
brachial artery at the bend of the elbow, as is liable to occur 
if they are applied when the arm is extended and afterwards 
flexed for support in the sling. 

Adjustment of the fragments is accomplished by extension 
and counter-extension with manipulation. Owing to the 
danger of exerting too much pressure with the turns of the 
primary roller, and in this way causing encroachment upon 
the interosseous space, it should be omitted. Two light 
board splints, one inch wider than the forearm, and long 
enough to extend from the ends of the fingers to the bend of 
the elbow, should be well padded, especially at the extremi- 
ties, and placed on the anterior and posterior surfaces of the 
limb, and secured in position by the spiral reverse band- 
age, carried to a sliort distance above the elbow. Care 
should be taken to adjust the splints, so that the sides extend 
beyond the surface of the limb both heloic and ahove. and thus 
avoid pressure upon the parts. Additional security against 
pressure by the ends of the splints can be obtained by placing 
masses of cotton-wool beneath them. The sling in which 
the forearm is placed should extend from the elbow to the 
wrist, so as to afford support to the entire forearm (Fig. 121). 
Inspection of the parts should be made daily for the first 



FRACTURES. 



199 



week, in order to guard against the dangers of undue pres- 
sure, and the dressings should be removed and re-applied if 
excessive swelling is present, or there are present any symp- 
toms of interference with the circulation. Where comminu- 




tion of either bone has occurred it is desirable to place a pad 
between the bones over the interosseous space to maintain this 
space. 

Uppkr Extremity op the Radius — Neck. Symp- 
toms. — In fracture of the bone at this point, which occurs 
very rarely, the symptoms are obscure. If the head of the 
bone can be grasped and held in a fixed position, while supi- 
nation and pronation are performed, crepitus may be elicited. 



200 FRACTURES. 

Pain on rotation of the bone will be experienced, mobility is 
not affected, and deformity is not marked. 

Diagnosis. — Owing to the absence of very positive symp- 
toms the diagnosis is difficult. Care is to be taken to distin- 
guish it from anterior dislocation of the head of the bone. 

Prognosis The proximity of the seat of fracture to the 

elbow-joint renders this joint liable to the invasion of inflam- 
mation and consequent anchylosis, unless means are taken 
to overcome it. 

Treatment. — Tlie forearm is to be placed in a state of su'pi- 
nation and flexed; in this position the anterior or posterior 
angular splint well padded (Figs. 118 and 119) is to be ap- 
plied and secured by a bandage. Efforts at breaking up any 
adhesions which may have formed in the elbow- joint should 
not be made until union has occurred, which usually takes 
place by the end of the fifth week, lest separation of the 
fragments occur with subsequent deformity. 

Shaft of the Radius — beloay the Tubercle. 

Symptoms Crepitus may be developed and pain produced 

by rotation of the forearm, the fiagments being approxi- 
mated ; deformity and undue mobility are not marked. 

Diagnosis The separation of the fragments under the 

influence of the action of the supinator brevis, causing exter- 
nal rotation of the upper fragment and of the pronator radii 
teres, producing internal rotation of the lower fragment, can 
be detected on careful examination. The symptoms are also 
usually so well marked as to assist in making the diagnosis. 

Prognosis If union should occur in the position of the 

fragment above described, the function of supination would 
be destroyed, and the use of the forearm much impaired. 

treatment The forearm should be supinated, flexed, and 



FRACTURES. 201 

the posterior angular splint or trough applied as in fracture 
of the neck of the radius. 

Middle of the Shaft. Symptoms. — In fracture at 
this point the symptoms are well defined ; the signs of frac- 
ture, deformity, preternatural mobility and crepitus, with 
pain and loss of the power of supination and pronation, are 
present, and can be readily recognized. 

Diagnosis The diagnosis is usually not difficult, owing 

to the well-defined character of the symptoms. The swell- 
ing which accompanies the injury may sometimes interfere 
with a ready recognition of the nature of the fracture. A 
study of the action of the muscles attached to the bone will 
explain the displacement which occurs, the upper fragment 
being raised and rotated inward by the combined action of 
the biceps arid pronator radii teres muscles, while the end of 
the lower fragment is directed toward the ulna by the action 
of the supinator longus and pronator quadratus. 

Prognosis The tendency of the ends of the two frag- 
ments to encroach upon the interosseous space results very 
frequently in obliteration of the space, and their union to 
the ulna by callus, in this way the function of supination 
and pronation being entirely destroyed. 

Treatment The adjustment of the fragments is accom- 
plished by flexing the arm and manipulating the lower frag- 
ment, so as to direct the upper end outward. Extreme 
adduction of the hand will assist in this effort. A narrow 
compress, extending from the upper margin of the pronator 
quadratus to a point just below the seat of fracture, should 
be placed on the anterior and posterior surfaces of the fore- 
arm to preserve the interosseous space. The forearm being 
placed midway between supination and pronation, the thumb 
directed upward, two well-padded straight splints, extending 



202 FRACTURES. 

from the elbows to the ends of the fingers, and projecting one 
inch above and below the borders of the limb, should be 
applied on the anterior and posterior surfaces, and should be 
held in position by a roller ; the arm should be supported in 
a sling. In some cases it may be advisable to substitute for 
the anterior straight splint the anterior angular splint, so as 
to maintain the arm in a flexed position. If difficulty is 
experienced in keeping the upper end of the lower fragment 
outward, the lower ends of the straight splints can be rounded 
off so as to secure the hand in the position of adduction. 

Lower Extremity. Symptoms In all of the varieties 

of fracture occurring at this point the symptoms are charac- 
teristic and usually well defined. Outside of those of swell- 
ing, pain, loss of function, and crepitus, deformity is most 
distinctive. In extra-articular fractures of the bone in 
which the line of separation is transverse, the displacement 
is in the long axis of the bone, with little or no lateral 
deviation, giving to the part that disfigurement which was 
designated by Velpeau as the silver fork deformity. In this 
form the lower fragment produces a marked prominence upon 
the posterior surface of the forearm, while the upper frag- 
ment projects anteriorly and to less degree. Abduction of 
the hand may be marked in this variety if there should exist 
with the fracture a rupture of the internal lateral ligament, 
or a fracture of the styloid process of the ulna. 

In that variety of fracture involving the joint in which 
the styloid process is separated by an oblique line of fracture, 
the abduction of the hand or lateral deviation to the radial 
side, affords most characteristic deformity, caused by the 
contraction of the extensor muscles of the thumb, ossis 
metacarpi pollicis, and primi and secundi internodii poUicis. 
In that form known as Rhea Barton's there is a prominence 



FKACTUKES. 203 

upon the posterior surface of the forearm produced by the 
displacement upward of tlie wedge-sliaped piece of bone split 
off from the articular end, with the carpus, forming a sub- 
luxation of the radius upon the carpal bones. The lateral 
displacement is also well defined with a marked projection 
of the styloid process of the ulna. Usually the upward 
displacement of the fragment of bone is not great. In a 
case, however, which came under my care in the surgical 
wards of St. Mary's Hospital, this city, I found the segment 
of bone occupying a position three and one-half inches above 
the line of the articulation. The patient, a lad eighteeD 
years of age, had fallen through a hatchway from a height 
of four stories, and had sustained a number of fractures : 
Barton's fracture of the left radius, with a compound fracture 
of both bones of the right forearm, and of the crest of the 
left ilium. He made a good recovery from all of the injuries. 
In all of the varieties of fracture of the lower end of the 
radius the swelling is usually very marked, and involves the 
entire surface. It is due to inflammatory effusions impli- 
cating the burs« which exist in connection with the tendons 
of the flexor and extensor muscles passing from the forearm 
to the hand across the radio-carpal joint. 

Diagnosis Fractures involving the lower end of the 

radius are to be distinguished from luxations of the wrist- 
joint, and careful examination is required to do this, the 
difficulties being greater in some instances than in others. 
In persons of advanced life, in whom the fracture most fre- 
quently occurs, the diagnosis is rendered less difficult by 
reason of the atrophic changes which have taken place in 
the overlying tissues. Luxations of the wrist-joint are 
accompanied by deformity which is due to the displacement 
of the hand in the long axis of the bone, the hand being 



204 FRACTURES. 

either flexed or extended according to the character of the 
dislocation ; lateral deviation, if present, is not so marked as 
in fracture. The permanent removal of the deformity after 
efforts at reduction with the absence of crepitus distinguishes 
luxation from fracture. It is important that the proper 
manipulation should be made in order to elicit crepitus. 
Simple rotation of the hand will not accomplish this. It is 
necessary that the head of the radius should be grasped and 
held firmly while the movements of supination and prona- 
tion are made. In this way the upper fragment remains 
fixed, and the lower fragment is moved eliciting crepitus. 
In some cases it may be necessary to grasp the upper and 
lower fragment near the line of fracture and move one over 
the other. 

Prognosis Unless the greatest care is exercised in con- 
ducting the treatment of fractures involving the lower end 
of the radius, more or less deformity with impairment of the 
functions of the wrist-joint and fingers is liable to follow. 
In certain cases it is impossible to avoid these conditions, 
despite the most careful attention, owing to the inflammatory 
products which are deposited within the sheaths of the adja- 
cent tendons and wrist-joint. Patients should be informed 
of the results which may occur, and their full cooperation 
should be required to assist in preventing, as far as possible, 
their occurrence. 

Treatment The indications to be met in the treatment 

-of these fractures are : to retain the lower fragment in posi- 
tion after reduction, by compresses, rollers, and splints, and 
to overcome the deviation to the radial side by so shaping 
the ends of the splint as to secure marked adduction. 

The dressing employed by Dr. Barton consisted in two 
graduated compresses two and one-half inches square, two 



FRACTURES. 205 

Straight wooden splints, the same as used in the treatment ot 
fracture of both bones of the forearm, and one roller two 
and one-half inches wide. Reduction is effected by flexing 
the arm and making extension while the lower fragment is 
pressed into position by manipulation with the thumb and 
fingers. In some cases it may be necessary to accompany 
the manipulation with forcible flexion at the wrist-joint in 
order to place the lower fragment into apposition. The 
adjustment of the fragments being maintained by extension 
and counter-extension, one of the compresses is placed on 
the anterior surface of the forearm, the base being on a line 
with the end of the upper fragment, and the apex directed 
upward ; the other compress is placed on the posterior sur- 
face, the base on a line with the upper end of the lower 
fragment, and the apex directed downward. These com- 
presses are now lightly secured in position by a roller begin- 
ning around the wrist and then carried to the hand and back 
to the wrist by figure-of-eight turns and by spiral turns, until 
the compresses are completely covered. The splints are now 
placed in position and held by spiral and spiral-reversed 
turns of the remaining portion of the roller, or it may be 
consumed in fastening the anterior splint, while a second 
roller may be used to hold the posterior splint by turns from 
the hand to the elbow. Care should be taken to apply the 
roller which secures the compresses in position loosely in 
order to avoid too much pressure, when the swelling which 
always occurs is present. For the first week careful daily 
examination should be made of the condition of the parts, 
and on the third day a renewal of the dressings should be 
made if no conditions have occurred to demand it earlier. 
During the remainder of the time required for the comple- 
tion of union, four to six weeks, redressings should be made 
18 



206 



FRACTURES. 



every third or fourth day. As early as the sixth or eighth 
day gentle motion of the wrist-joint and fingers, including 
flexion, extension, and rotation, should be instituted and con- 
tinued at each redressing. These movements should be 
gradually increased, and after the second or third week the 
wrist and hand can be soaked in hot water, and, after being 
dried, manipulated and rubbed with soap liniment. At the 
expiration of the fifth or sixth week the splints may be dis- 
pensed with, and the limb, covered simply with a roller, may 
be carried in a sling. The manipulations of the wrist-joint 
and fingers should be continued, the patient being instructed 
as to those which should be made in order to restore the func- 
tions of the part. This plan of treatment, if persevered in 
faithfully, will remove the rigidity of the articulation which 
inevitably follows fracture at this point, and enable the 
patient to regain, to a great degree, if not completely, the 
function of flexion, extension, supination, and pronation. 



Fig. 122. 




In cases of fracture of the styloid process, with or without 
dislocation of the ulna, in which there is a tendency to 



FRACTURES. 



207 



marked tulduction of the hand, it is desirable to employ a 
form of splint which will accomplish adduction and at the 
same time maintain the fragments in position. For this 
purpose Nelaton's pistol-shaped splint (Fig. 122), Bond's 
splint (Fig. 123), that of Coover (Fig. 124), or Levis's may be 

Fig. 123. 




applied with advantage. Bond's and Coover's splints secure 
tlie parts in a natural position, that is, extension of the hand 



Fiff. 124. 



t 



G TIEMANM&CO 




Upon the forearm with flexion of the fingers and slight adduc- 
tion. Graduated compresses with short posterior splints are 



208 FRACTURES. 

to be used with these splints in order to overcome the dis- 
placement when it may be necessary. In the description of 
fractures of the lower end of the radius the terms abduction 
and adduction have been employed with reference to the 
body ; the upper extremity being in the anatomical position 
with the palms of the hand presenting forward. 

Upper Extremity of the Ulna — Olecranon Pro- 
cess. Symptoms In fractures of this process below the 

point of insertion of the triceps muscle, the displacement 
upward of the fragment is usually so well marked as to be 
easily recognized. A depression or sulcus exists between 
the fragment and the shaft of the bone into which the end 
of the finger can be placed when the forearm is flexed ; the 
extension of the forearm is usually impaired, although com- 
plete loss of this power is not frequent. Where the line of 
fracture is above the insertion of the triceps muscle there is 
little or no displacement of the upper fragment. Pain and 
swelling are present in almost all cases. Crepitus may be 
elicited by extending the forearm and drawing down the 
upper fragment so as to approximate it to the shaft. 

Diagnosis The diagnosis is made by a careful study of 

the symptoms present. The diagnostic signs are the dis- 
placement of the upper fragment, in some cases reaching to 
two inches above the point, the sulcus between the upper 
fragment and the shaft of the bone in flexion of the forearm, 
the want of relation of the process to the condyles of the 
humerus, the impairment of the function of extension of the 
forearm. 

Prognosis — Union after fractures of this process occurs 
by fibrous tissue and with more or less separation of the frag- 
ments. In cases in which the fracture is accompanied by 



FRACTURES. 



209 



severe injury to the joint, adhesions are liable to occur pro- 
ducing anchylosis. 

Treatment Tlie treatment in fracture of the olecranon 

process consists in overcoming the action of the triceps 
muscle, so as to maintain the detached fragment in apposi- 

YW. 125. 




Fiar. 126. 




tion witli the shaft of the bone. To accomplish this pur- 
pose the arm must be kept in the extended position after the 
fragment has been drawn down and secured in contact with 
the shaft by figure-of-eight turns of a bandage or by one or 
morestripsof adhesive plaster applied in this way. (Fig. 125.) 
Over this the spiral reverse bandage of the arm should be ap- 
plied extending to the shoulder, and a splint either straight or 
with a very slight angle well padded, and reacliing from the 
axilla to the wrist, should be placed on the anterior surface 
of the arm and secured in position by the turns of a roller. 
(Fig. 126.) Objection is made to the use of the straight splint 
on account of tlie discomfort which attends the maintenance of 
the arm for a long period of time in a state of full extension. 

18* 



210 FRACTURES. 

In cases in which severe injury has been inflicted upon the 
soft tissues and acute inflammation has supervened, it is ne- 
cessary that measures should be taken to abate the inflamma- 
tion by the application of leeches, and after, of sorbefacient 
lotions, as laudanum and lead- water, the arm being mean- 
while placed in an extended position upon a pillow. 

When the inflammation has sufficiently subsided the per- 
manent dressings may be applied. Passive motion should be 
instituted with care at the end of the second week and the 
parts bathed in warm water and well rubbed with soap lini- 
ment. If bony anchylosis is inevitable the arm should be 
placed in the flexed position, which is that of most service. 
In a case, which came under my care, of recent union of the 
fracture with the arm in the straight position in a lad ele- 
ven years of age, I succeeded in establishing very good 
motion in the joint by refracturing the process and permitting 
union to take place with a separation of the fragments to the 
extent of one-quarter of an inch. To accomplish this 
required persevering efforts continued for many weeks, an 
ansesthetic being administered on each occasion. 

CoRONOiD Process. Symptoms The extreme rarity 

of this fracture has prevented extended study of the symp- 
toms. In order to develop any of a marked character a 
posterior luxation of the joint must be present as one of the 
most prominent, and fracture of the process may be estab- 
lished by determining the tendency of luxation to recur after 
efforts at reduction have ceased. The fragment may be felt 
in front of the joint, to which position it has been carried by 
movements of the joint and the action of the brachialis anti- 
cus muscle partially. If the line of fracture is through the 
base of the process, the action of the muscle in elevatino- tlie 
fragment will be more marked. Crepitus may be detected 



FRACTURES. 211 

in some cases by placing the arm in a state of extreme flexion 
and approximating the process to the shaft. 

J}iagnosis. — Owing to the absence of well-marked svmp- 
toms the diagnosis is diflficult. Many cases of reported frac- 
ture of the process are believed to be based upon incorrect 
diagnoses, as it seems requisite in most cases to have the con- 
dition verified by autopsy. 

Prognosis The union of the process, after fracture to the 

shaft, occurs by fibrous tissue. The functions of the part are 
very little, if any, impaired, although some stiffening of the 
elbow-joint may result from disuse during treatment, with 
anchylosis, if inflammation has followed the injury to the 
joint inflicted at the time of fracture. 

Treatment. — The arm being flexed the spiral reverse band- 
age is applied with careful figure-of-eight turns about the 
elbow-joint, so as to secure approximation of the detached 
process, and a posterior right angled splint or trough is fas- 
tened to the arm by the turns of a second roller. If it is 
found necessary to make pressure over the seat of fracture 
so as to assist in holding the fragment in position, compresses 
may be applied, and the anterior angular splint employed, 
care being taken by counter-pressure over the posterior sur- 
face of the joint to prevent displacement backward of the 
ulna and radius. 

Shaft of the Ulxa. Symptoms Owing to the fixed 

position of this bone as compared with that of the radius and 
the absence of the insertion of any muscles into the middle of 
the shaft which would conspire to produce to any marked 
extent displacement after fracture, deformity is frequently 
absent. In some cases it occurs as a result of the fracture- 
producing force, and the action of the pronator quadratus 
upon the lower fragment, when the other symptoms of frac- 



212 FRACTURES. 

ture, mobility and crepitus, are also present in marked degree, 
and are easily detected. 

Diagnosis The subcutaneous position of the outer bor- 
der of the bone enables the surgeon to detect the seat of frac- 
ture by passing tlie finger over this border, and crepitus can 
be elicited by manipulation. 

Prognosis Unless care is taken to keep the upper end 

of the lower fragment from encroaching upon the interosseous 
space union may occur so as to attach the fragments to the 
border of the radius, and in this way destroy the important 
movements of supination and pronation. Non-union of the 
fragments sometimes occurs in patients who are the subjects 
of some constitutional taint. Immobility of the fragments 
can be so readily obtained that it would seem to be impos- 
sible for it to result from the want of proper adjustment and 
retention. 

Treatment The indications for treatment are to secure 

by manipulation the proper adjustment of the fragments, and 
by position of the hand and the application of compresses 
and splints, to so retain them as to preserve the integrity of 
the interosseous space. The primary roller should be dis- 
pensed with in order to avoid pressing the fragments into 
the interosseous space. The forearm being in a position of 
semi-pronation, compresses are placed so as to preserve the 
adjustment which has been effected, and an anterior and 
posterior splint well padded are applied, extending from the 
elbow to the ends of the fingers, and are secured by the turns 
of a roller. A sling, extending from the elbow to the wrist, 
should be employed to support the arm. 

Lower Extremity of the Ulna — Styloid Process. 
Symptoms — The symptoms most marked in fracture of this 
process is deformity produced by a displacement of the hand 



FRACTURES. 213 

towards the radial side of the forearm. Pain on movement 
of the hand, with more or less swelling of the joint, is pre- 
sent. The fragment may be grasped, if the swelling is not 
too great, and preternatural mobility established. 

Diagnosis The diagnosis is to be made by careful ex- 
amination of the parts so as to ascertain the movement of 
the process under manipulation. Crepitus, if elicited, will 
be quite indistinct. The roughened surface of the lower end 
of the upper fragment may be felt if the swelling is not too 
great. 

Prognosis The small size of the detached fragment, 

with the displacement forward of the tendon of the extensor 
carpi ulnaris, which is placed in a groove behind the pro- 
cess, interferes with an accurate adjustment and retention of 
the fragments, and results in more or less deformity. Union 
is by fibrous tissue. 

Treatment The hand should be carried from the radial 

side and extended, and an effort made to adjust the frag- 
ment by manipulation. Adjustment having been effected, a 
compress should be placed over the seat of fracture, and a 
Bond or Coover splint (Figs. 123, 124) applied, and secured 
in position by the turns of a roller. A sling to support the 
arm will complete the dressing. 

Hand. — Fractures of the hand include those of the carpus, 
metacarpus, and phalanges. 

Causes — The causes of fracture of the diflferent parts of 
the hand are, as a rule, direct force, and usually of such 
nature as to render the injury compound in character — as 
crushes in machinery and gunshot wounds. The metacarpal 
bones are frequently fractured by indirect force, as from blows 
given with the fist, the violence being inflicted upon the 
distal extremities of the bones. 



214 FRACTURES. 

Carpus. Symptoms Owing to the arrangement of the 

carpal bones with regard to the synovial membranes which 
line the articular surfaces, and the intimate relation of the 
tendons which cross the carpus anteriorly and posteriorly, 
any injury which would cause fracture of these bones would 
be attended by marked swelling. Crepitus might be detected 
by performing flexion and extension of the hand. Pain, 
with loss of function, would be present. 

Diagnosis The detection of crepitus is necessary to 

establish the existence of fracture, as the other symptoms of 
pain, swelling, and loss of function accompany equally well 
contusion or severe strain of the carpal joints. Where ex- 
tensive comminution of the bones has occurred, crepitus may 
be detected without much difficulty. In compound fractures 
of the carpus, the parts can be explored with the probe or 
finger, and in some instances inspected, and the character of 
the injury determined. 

Prognosis In simple fracture of any of the carpal bones, 

unaccompanied by severe injury to the parts, the prognosis 
is favorable. Consolidation of the bones may follow exten- 
sive involvement of the parts by inflammation and marked 
impairment of function may occur as a result. 

Treatment. — Compresses being placed, if necessary, over 
the seat of fracture, the hand is extended and placed on an 
anterior splint, w^hich should extend from the middle of the 
forearm to the ends of the fingers. On that part of the splint 
occupied by the palm of the hand, a pad, made of a roller 
bandage or a mass of oakum, should be placed so as to secure 
proper extension of the hand, and preserve the concave shape 
of the palm (Fig. 127). The splint thus prepared should be 
held in position by a bandage, and the forearm supported 
in a sling. In compound fractures of the carpal bones the 



FRACTURES. 215 

FiV. 127. 




question of excision or amputation is to be carefully con- 
sidered. Primary amputations should, as a rule, be avoided, 
in the hope that the reparative process may proceed to a 
successful termination, with the preservation of a useful 
member. 

Metacarpus. Symptoms. — The usual symptoms of frac- 
ture are present in fracture of these bones, as pain, deformity, 
mobility, and crepitus. The deformity varies in accordance 
with the nature of the fracture-producing force, if it is di- 
rectly applied, and the line of separation is transverse, the 
displacement is very slight, if any. Where the force is ap- 
plied indirectly upon the distal ends of the bones the line 
of fracture is oblique, and an overlapping of the fragments 
occurs, causing a projection upon the palmar and dorsal sur- 
faces, and a depression over the metacarpo-phalangeal joint. 
Mobility and crepitus may be detected by grasping firmly the 
upper fragment with the thumb and finger of one hand, and 
the metacarpo-phalangeal articulation with the other hand, 
and moving the fragments upon each other. 

Diagnosis The symptoms are usually sufficiently dis- 
tinct to render the diagnosis easy. The ease with which the 
parts can be examined and manipulated assists in establish- 
ing the diagnosis. 

Prognosis Union takes place readily, attended very 

frequently by a deposit of callus, which produces a slight 
deformity on the dorsal surface. Necrosis of the bone 
may occur, with involvement of the wrist and metacarpo- 



216 FEACTUEES. 

phalangeal articnlation by inflammarionj resultiog in some 
instances in anchylosis of these joints. 

Treatment. — The treatment is the same as that described 
in connection with fracture of the carpal bones. Fracture 
of the metacarpal bone of the thumb requires the application 
of a splint made so as to support both the thumb and palm 
of the band, to which thej are held by turns of a roller. 

Phalanges. Sy^mptoms — In fractures of the phalanges 
the symptoms are well marked. 

Diagnosis. — Under almost all conditions crepitus can be 
detected, and the existence of fracture determined without 
much difficulty. 

Prognosis In simple fracture union occurs with little 

or no deformity. As in fracture of the metacarpal bones, 
necrosis may accompany fracture of a phalanx, and anchy- 
losis of an adjacent articulation may result from inflamma- 
tory action. 

Treatment. — Simple fracture of the phalanx may be treated 
by the application of a splint made from a piece of binders* 
board, which has been soaked in hot water and moulded to 
the palmar and lateral surfaces of the finger. A second 
splint of wood, long enough to extend from the wrist to a 
slight distance beyond the end of the finger, should be ap- 
plied upon the dorsal surface (Fig. 128). Both splints should 
be well padded and held in position by turns of a finger band- 
age, one-half of an inch in width, carried over the hand and 
terminating at the wrist. In some cases I have held the 
fragments in position by narrow strips of adhesive plaster 
applied on the palmar, dorsal, and lateral surfaces. Two 
strips are required for the purpose, which should be carried 
over the tip of the finger, the application beginning at the 
base. A third strip is now applied by spiral turns, begin- 



FRACTURES. 



217 



ning at the end of the finger and proceeding to the base, 
securing the pahnar, dorsal, and lateral strips in position. 
The dressing is completed by placing the hand upon a palmar 
splint, as in fracture of more than one phalanx. When union 

Fig. 125. 




has sulficiently progressed, at the end of a week or ten days, 
the palmar splint may be dispensed with, care being taken 
to avoid striking the end of the finger, and causing separation 
of the fragments. 

In compound fractures of the fingers, efforts should always 
be made to obtain repair without sacrificing any of the parts. 
In a large number of severe injuries of the hand and fingers 
caused by crushes in machinery, which have come under my 
care in hospital and private practice, I have invariably re- 
frained from the use of the knife. By means of adhesive 
plaster and antiseptic dressings I have succeeded in saving 
fingers which offered very little hope of success in obtaining 
repair. As has been well stated by the late Professor Gross, 
** It is here that conservative surgery may often display its 
highest excellence." 

Pelvis. 

Fractures of the bones entering into the formation of the 

pelvis occur as the result usually of great violence, such as 

crushes between the drawheads of railroad cars, the passage 

of the wheels of a car or heavily loaded wagon, or falls 

19 



218 FRACTURES. 

from great heights. They may be complicated by grave 
injury to the important organs contained within the pelvic 
cavity, as the bladder or rectum, causing rupture of the 
former and infiltration into the cavity of its contents. Dis- 
location may be associated with fracture, and necrosis may 
occur, resulting in the loss of large pieces of bone. Gun- 
shot fractures occur frequently, involving, as a rule, either 
some of the abdominal or pelvic viscera. Of the diiferent 
bones of the pelvis, the ilium, by reason of its more exposed 
position, sustains fracture most frequently. 

Sacrum. Causes The cause of fracture of this bone 

is great violence applied directly, as a blow upon the part, 
fall from a height, or passage of the wheel of wagon or car, 
producing a fracture in the oblique, transverse, or, more 
rarely, vertical direction. 

Symptoms In addition to the symptom's attending 

fractures, there are frequently those indicating involvement 
of the pelvic viscera and nerves of the sacral plexus, as 
paralysis of the lower extremities, retention of the urine, 
and involuntary passage of the feces. Great pain is felt on 
movement of the body or on attempts at defecation or uri- 
nation. 

Diagnosis Inspection of the part will frequently detect 

displacement of the fragments. Crepitus can be elicited by 
pressure exerted by the index finger of one hand introduced 
into the rectum while the other hand is placed over the 
external surface. Mobility can be detected in the same 
manner. 

Prognosis In simple fracture without serious involve- 
ment of the contents of the pelvic cavity the prognosis may 
be regarded as favorable. The violence required to produce 
fracture of the bone is usually so great as to necessarily 



FRACTURES. 219 

inflict injury upon the structures within the cavity and as a 
result render the prognosis doubtful. 

Treatment. — Efforts should be made carefully to over- 
come any displacement which may exist by pressure and 
counter-pressure, by means of the index finger or a strong 
vesical sound introduced into the rectum, while counter- 
pressure is made over the external surface. Over the seat 
of fracture a compress should be placed and held in position 
by a T-bandage. In cases in which the anterior displace- 
ment is so great as to require pressure constantly applied, a 
rectal bougie of proper length and size can be inserted and 
retained by means of a bandage. This instrument should 
be removed every third day and the bowel washed out vvith 
warm water belbre its re-introduction. The patient should 
rest upon his back on a firm mattress with the extremities 
flexed and supported on pillows, and, if necessary, the pres- 
sure removed from the sacrum by the intervention of an air 
cushion or well-padded ring. Attention should be given to 
the condition of the bladder and rectum. If retention of 
urine exists, the catheter should be introduced four or six 
times in the twenty -four hours. If rupture of the bladder 
has occurred in connection with the fracture, a gum catheter 
should be kept in the organ so as to prevent the escape of 
urine into the surrounding tissues. The occurrence of inflam- 
mation in the organs of the pelvic cavity should be met by 
the employment of antiphlogistic measures. Constipation 
of the bowel should be favored during the early stage of the 
treatment in order to avoid disturbance of the fragments. 
After that period injections of warm water may be employed 
from time to time to remove the accumulation of feces. 

Coccyx. Causes Fracture of this bone may occur as 

the result of violence applied directly over the part, as that 



220 FRACTURES. 

from a kick or fall, or it may be caused by inordinate pres- 
sure backward by the head of the child in its escape from 
the pelvis during parturition. 

Symptoms Acute pain is experienced on movement, 

and crepitus may be produced by introducing the finger 
into the rectum and making pressure, combined with counter- 
pressure over the external surface with the fingers of the 
other hand. Preternatural mobility may be detected by 
the same manipulation. Deformity is not apparent. 

Diagnosis. — The existence of fracture can be determined 
by the introduction of the finger into the rectum. The his- 
tory of the case will assist in arriving at the diagnosis. 

Prognosis In many cases' the prognosis is unfavorable 

owing to the difficulty of obtaining union without deformity, 
and the extremely painful conditions which follow impli- 
cation of the nerves in relation with the bone. Violent 
neuralgia — coccygodynia — frequently occurs after fracture, 
requiring excision of the bone. In two instances I have 
performed coccygectomy with entire relief from the most 
distressing sufferings ; both operations were performed in 
females who had sustained fracture of the bone by falls upon 
the nates. 

Treatment Adjustment of the fragments should be 

effected, if displacement exists, by pressure and counter- 
pressure, the finger being introduced into the rectum to 
accomplish this successfully and a compress secured by 
bandage or adhesive strips should be placed over the parts. 
The patient should be kept perfectly quiet, resting in the 
recumbent position upon the side. Enemata should be 
given carefully every other day so as to prevent constipa- 
tion. If the tendency to anterior displacement is very great 
an effort should be made to overcome it by the introduction 
of a rectal bougie as in cases of fracture of the sacrum. 



FRACTURES. 221 

Os iNNOMINATU.'Sr. 

Ilium. Cavses. — Great violence applied directly over 
the bone may cause fracture either in the body or crest. 
Falls from a height, during which the crest of the bone may 
come in contact with projecting surfaces may detach portions 
of the rim. Gunshot wounds are also a frequent cause of 
fracture of this bone. 

Symptoms Pain is a prominent symptom in fractures of 

the ilium especially developed on movement. Deformity, 
with mobility, may be recognized when the crest or one of 
the anterior processes is detached. In these instances crepi- 
tus may also be elicited. In extensive crushes of the bone 
these symptoms will be more marked, accompanied frequently 
by those of injury of some of the viscera. 

Diagnosis Careful examination of the part will enable 

the surgeon frequently to detect the seat of fracture, and by 
manipulation elicit crepitus. Often the symptoms are so 
obscure as to render the diagnosis difficult. 

Prognosis The prognosis is influenced largely by the 

character of the injury. In simple fi-actures it is very favor- 
able, while in compound fractures, or in those in which 
serious injury has been inflicted upon the abdominal or 
pelvic viscera, the prognosis is doubtful. 

TreatmerH The position of the patient in bed must be 

that which will secure most effectually adjustment of the 
fragments. That which the patient usually assumes, as afford- 
ing most relief from pain, is elevation of the head and shoulders 
with flexion of the lower extremities upon the abdomen 
accompanied, in some instances, by an inclination of the 
body to the affected side. When reduction is effected the 
fragments should be held in position by a strong, broad 

19* 



222 FRACTURES. 

.bandage enveloping the pelvis, or adhesive strips, one and a 
half to two inches in width, may be applied in oblique and 
circular directions, covering in the entire bone so as to hold 
the fragments in apposition. Where comminution of the 
bones has occurred in compound fractures, the detached 
pieces should be removed, as they are liable to undergo 
necrosis and interfere with repair. Careful attention is to 
be given to the condition of the bladder and bowels, the 
catheter being employed if necessary to empty the former at 
stated intervals ; the latter should be evacuated by enemata 
in the recumbent position, the bed-pan being used for the 
purpose. 

PuBES. Causes. — The causes concerned in the pro- 
duction of fracture of the pubes are similar to those which 
exist in fracture of the ilium, namely, extreme violence 
applied directly over the part. Separation at the symphysis 
is reported to have occurred in a number of instances during 
the passage of the head of the child through the pelvis in 
parturition. Violent abduction of the thighs may also pro-* 
duce fracture, force being applied in this manner indirectly. 
The seat of fracture is most frequently in the rami, the body, 
except in cases of comminution, usually escaping injury. 

Symptoms — A prominent symptom in fracture of the 
pubes is the difficulty experienced in maintaining the erect 
position or in progression ; in severe cases an entire inability 
to stand or walk exists. Deformity is not marked, mobility 
and crepitus may be distinguished by manipulation ; pain 
accompanies movements or pressure over the parts 

Diagnosis Manipulation in the form of pressure or 

counter-pressure will enable the surgeon usually to elicit 
crepitus and ascertain the point of fracture. In the female 
the introduction of the finger into the vagina will assist 



FRACTURES. 223 

materially in this manipulation. Mobility and crepitus may 
be produced in some instances by grasping the tuberosity of 
the ischium with one hand and the body of the bone with 
the other and moving the fragments upon each other. 

Prognosis In simple cases the prognosis is favorable. 

In cases complicated by comminution of the bones or rup- 
ture of the bladder the prognosis is grave, owing to the 
dangers which may arise from inflammatory action and 
urinary infiltration. 

Treatment — Tlie treatment of fractures of the pubes so 
far as relates to the maintenance in apposition of the frag- 
ments is similar to that employed in fractures of the ilium. 
The thighs should be flexed upon the abdomen and a broad 
bandage should be applied around the pelvis, a compress 
being placed over the pubes to overcome any displacement 
which may exist. Prof. Agnew employs in preference adhe- 
sive strips four inches in width and long enough to extend two- 
thirds around the pelvis ; to prevent adhesion to the hair 
covering the pubes a piece of muslin should intervene. The 
most important point to be considered in the treatment of 
fracture of the pubes relates to the condition of the bladder. 
In all cases the catheter should be introduced and should be 
allowed to remain until the condition of the organ is definitely 
ascertained. If rupture has occurred the instrument should 
be kept in position for six to eight days with a view to keep 
the organ empty during the repair of the wound. If lacer- 
ation of the urethra has occurred, perineal section should be 
at once performed in order to prevent urinary infiltration. 
Wiien infiltration takes place into the scrotum or perineum, 
free incisions should be made to permit escape of the fluid 
and prevent sloughing. 



224 FRACTURES. 

Ischium. Causes Fracture of this bone occurs less 

frequently than that of the other bones of the pelvis, owing 
to its protected position. It may be broken in the ramus 
or tuberosity, the causes being external violence applied 
directly, as in blows or falls upon the buttocks. 

Symptoms Inability to stand or walk is the most 

characteristic symptom of fracture of this bone. It is 
especially marked in cases in which comminution of the 
bone has occurred involving the points of origin of the 
powerful flexor muscles of the thigh. Pain on movement 
is felt. Mobility and crepitus can be recognized on manipu- 
lation. Deformity is, as a rule, absent. 

Diagnosis — The diagnosis is made by careful exami- 
nation of .the parts. Crepitus may be detected by grasping 
the tuberosity and moving the fragments while in contact. 
In corpulent individuals the diagnosis is rendered more diffi- 
cult owing to the mass of overlying soft tissues. 

Prognosis.' — Injury of the bladder or urethra is liable to 
occur and complicate fractures of this bone as in those of 
the pubes. 

Treatment — The apposition of the fragments in this frac- 
ture is accomplished by position of the patient, which should 
be upon the back with the lower extremities flexed and 
fastened together, and the buttocks supported in an air 
cushion. Careful attention should be given to the condition 
of the bladder. If rupture of it or of the urethra has 
occurred, the treatment should be the same as that directed 
in fracture of the pubes. 

Acetabulum. Causes Fractures of this cavity may 

occur either in the floor or rim, and are produced by vio- 
lence applied directly over the great trochanter, forcing the 
head of the femur against the floor, or indirectly, by falls 



FRACTURES. 225 

upon the knees or feet, driving the head against the border 
with undue force. 

Symptoms. — The symptoms of fracture of the acetabulum 
are very obscure, and owing to the relations existing between 
the cavity and the head of the femur, difficult to distinguish 
from those of fractures of the neck and dislocations of this 
bone. Simple fissures of the floor of the cavity are unat- 
tended by any symptoms which would make their recog- 
nition possible. Where the head of the femur is driven 
through the floor of the cavity, crepitus on making move- 
ment may be detected. Mobility and deformity are not 
characteristic. Pain is not distinctive and arises largely 
from the condition of the soft structures which, in an injury 
competent to produce this form of fracture, must be exten- 
sively contused. In fractures of the rim of the cavity, 
crepitus is usually present ; when displacement has occurred, 
deformity and mobility are present as in dislocation. 

Diagnosis The obscurity of the symptoms renders the 

diagnosis very difficult. In fracture of the rim it is to be 
made largely by the exclusion of such symptoms as indicate 
fracture of the neck of the femur. Fracture is to be distin- 
guished from dislocation mainly by the recurrence of the 
displacement after reduction. In fracture of the floor or of 
the rim of the acetabulum, crepitus is to be elicited by 
efforts at extension and relaxation rather than by rotation 
and flexion, as in fracture of the neck of the femur. In 
the female, examination, per vaginam, may assist in detect- 
ing fracture of the floor of the acetabulum. 

Prognosis Except in cases in which injury has been 

inflicted upon the organs of the pelvic cavity the prognosis 
is favorable. Simple fracture of either the floor or rim of 
the cavity is not usually attended with danger. 



226 FRACTURES. 

Treatment The treatment should be conducted upon the 

same principle as that of fracture of the femur. Extension 
and counter-extension with lateral pressure will overcome 
the tendency to displacement and maintain the parts at rest. 
To secure extension, weights should be attached to the limb 
by adhesive strips, with a cord passing over a pulley (Fig. 
96). Counter-extension can be accomplished by elevating 
the foot of the bed, and lateral pressure may be made by a 
broad band carried around the pelvis, over the great trochan- 
ter, or, if preferred, a broad strip of adhesive plaster may 
be employed. In some cases it may be found advantageous 
to treat the fracture by position ; suspending the limb by 
application of Smith's anterior splint. Careful attention 
should be given to the condition of the bladder. 

Lower Extremity. 

Femur Fractures of the femur are divided into those 

which occur in the upper extremity, shaft, and lower extrem- 
ity. Those of the upper extremity are sub-divided into the 
intra-capsular, those within the capsule of the hip-joint, and 
extra-capsular, those without the insertion of the capsule. 

Intra- Capsular Fractures. Causes In considering 

the causes of fracture of the neck of the femur it is necessary 
to examine briefly the changes which occur in this portion 
of the bone under the influence of age, and the difference in 
the angle at which the neck joins the shaft in the adult male 
and female subject. It was formerly believed that as age 
advanced an increase in the inorganic salts occurred through 
which the bone became more fragile and thus yielded more 
readily to fracture. More recent investigations have shown, 
however, that a change in the structure occurs which causes 
great disturbance of the nutrition of the neck of the bone, 



FRACTURES. 227 

the cells of the spongy tissue becoming rarefied and filled 
with fat, the compact layer thinned and the entire neck di- 
minished in size. Tliis change is more liable to occur in 
females than in males. Moreover, in the adult female the 
angle at which the neck joins the shaft approaches nearly a 
right angle, and the weight of the body is thus transmitted 
more directly upon the neck. It is also occasionally ob- 
served in very old persons, and especially in those much de- 
bilitated, that the direction of the neck is horizontal, the 
head sinking below the level of the trochanters and, owing 
to the decrease in the length of the neck, becoming almost 
contiguous with the shaft. It can be readily understood 
that these conditions predispose to the occurrence of fracture, 
which in a majority of cases takes place as the result of very 
slight force, such as that caused by a misstep in walking from 
the curb to the street, or in alighting from a carriage ; in some 
cases a fall upon the knee or trochanter will produce it ; in 
still others the muscular effort exerted in turning in bed is 
sufficient to accomplish intra-capsular fracture. The line of 
fracture varies according to the manner in which the force 
is applied, being oblique or, rarely, transverse ; — the separation 
of the fibres is, as a rule, complete. Impaction of the frag- 
ments occurs in a number of cases, the lower fra^rment beinoj 
driven into the upper, and by an interlocking of the fibres 
is held firmly in this position. In some cases the line of 
fracture extends beyond the insertion of the capsular liga- 
ment, forming a mixed variety of fracture, partly intra- and 
partly extra-capsular in character. Epiphyseal separation 
may occur in young subjects as the result of violence, but is 
regarded as of rare occurrence. 

Symptoms — The symptoms which indicate intra-capsular 
fracture are usually well marked. Loss of function is mani- 
fested by the inability of the patient to stand, or in some 



228 FRA.CTCRES. 

cases to exert any movement of the limb. In cases of im- 
paction the loss of function is not very distinct, patients ex- 
hibiting great control over the limb. Pain is well marked 
in most instances, and is increased on movement ; it is referred 
to the position of the joint, and is deep-seated in character. 
It may extend downward some distance on the inner aspect 
of the thigh. The deformity varies according to the extent 
of separation of the fragments ; in those cases in which the 
fracture is the result of force applied directly, the separation 
of the bony fibres is liable to be more complete than when 
it is the result of the application of indirect force or of mus- 
cular contraction. In the former, shortening is more marked 
and prompt in its occurrence, while eversion of the foot is 
pronounced ; in the latter the shortening, which is slight at 
first, gradually increases and eversion of the foot becomes 
prominent. Cases occur in which the shortening takes 
place very slowly, extending over a period of weeks and 
months, being due to a gradual absorption of the neck of the 
bone. The shortening varies from one-half of an inch to 
one inch and a half in the ordinary cases. When the cap- 
sular ligament is torn the shortening may be greater, reach- 
ing to two or more inches. 

Cases are recorded in which the position of the foot was 
that of inversion instead of eversion ; these positions are 
anomalous, and are explained as being due to a paralysis of 
the external rotator muscles. 

When impaction does not exist, crepitus may be elicited 
by placing the fragments in apposition and rotating the limb. 

Preternatural mobility is difficult of recognition owing to 
the relation of the fragments to the joint ; by careful manipu- 
lation, however, exaggerated motion may be detected. 

Diagnosis — The symptoms of intra-capsular fracture are 



FRACTURES. 229 

usually so distinct as to free the diagnosis from great diffi- 
culty. The age of the patient and the nature of the exciting 
cause are to be considered in arriving at a conclusion. 
These conditions, as has been observed above, exert an 
influence in determining the character of the injury. In 
cases oF impaction the absence of marked symptoms render 
the diagnosis very difficult. It is, moreover, very important 
to avoid extended manipulation in these cases lest the favor- 
able conditions of impaction be disturbed. In any case, 
violent manipulations should be avoided as they have a 
tendency to sever periosteal attachments which may exist, 
and to separate the fragments. The position of the seat of 
pain, deep in the groin over the inner and upper part of the 
femur, may be regarded as characteristic. Loss or impair- 
ment of function accompanies, to a greater or less extent, 
various forms of injuries occurring in connection with this 
region. In intra-capsular fracture it varies in accordance 
with the nature of the fracture. Deformity, as manifested 
by shortening of the limb and eversion of the foot, is present, 
and varies in accordance wnth the displacement of the frag- 
ments. In impacted fractures the deformity is slight, both as 
regards shortening and eversion of the foot. Crepitus may 
be elicited by extending and rotating the limb, while the 
upper fragment is grasped by the hand, or it may be pro- 
duced by flexing the thigh upon the pelvis and rotating the 
limb, while extension is made to keep the fragments in 
apposition. Preternatural mobility can be best exhibited 
by placing the patient on the abdomen and carrying the limb 
backward, as practised by Maisonneuve. By this manipu- 
lation the limb can be carried much further backward if 
broken than when no fracture is present, the intact neck of 
the bone coming in contact with the rim of the acetabulum 
20 



230 FRACTURES. 

and limiting the movement. Comparison of the position of 
the great trochanters, in fracture of the neck of the femur, 
will show a difference between that of the sound and injured 
side ; that on the injured side will be much less prominent, 
and on rotation of the limb will describe a much shorter arc 
of a circle. 

Prognosis The fact that intra-capsular fractures occur, 

as a rule, in elderly subjects renders the prognosis as to the 
ultimate results unfavorable. The danojers arisincr from the 
confinement in bed for a long period of time of persons 
enfeebled by age are obvious, and should be avoided in any 
plan of treatment adopted. Where the injury is the result of 
great violence the effects are very liable to complicate the 
fracture and to affect the prognosis. In cases of ligamentous 
union or non-union of the fragments disability to a greater 
or less extent always follows. 

Much discussion, and that apparently which has been 
profitless, has taken place with regard to the occurrence of 
bony union after intra-capsular fracture. Non-union may 
occur, under certain conditions, in any bone after fracture. 
Certain conditions attend this form of fracture which con- 
duce to non-union. The causes of non-union which are 
stated are deficient vascularity of the upper fragment, the 
presence of the synovial fluid and the want of proper co- 
aptation and maintenance in a fixed position of the frag- 
ments. In cases in which the fracturing force or the inju- 
dicious manipulations of the surgeon have caused w^ide 
separation of the fragments, one of the causes above 
enumerated would become active in preventing bony union. 
The great mobility of the upper fragment renders it almost 
an impossibility to secure an accurate adjustment with the 
lower fragment and its position in the acetabulum inter- 



FRACTURES. 231 

feres witli maintaining it in a fixed position. In such 
instances ligamentous union or non-union occurs simply 
from the want of full and complete contact of the fractured 
surfaces, and not on account of a deficient supply of blood 
or the presence of the synovial fluid. In impacted fractures 
or in Q^.ses in which a fracture has occurred without any 
displacement of the fragments, bony union does undoubtedly 
occur if this relation of the fragments is not disturbed, and 
it occurs in obedience to the laws which control repair in 
all fractures. In fractures of the patella, bony union takes 
place when the fragments are accurately adjusted and main- 
tained in perfect contact, notwithstanding a deficient blood 
supply and the presence of the synovial fluid; ligamentous 
union occurs in those cases in which perfect adjustment and 
fixation of the fragments are not accomplished. 

The following propositions may be stated with regard to 
the repair which follows in intra-capsular fractures of the 
femur. 

1. Bony union may occur after intra-capsular fracture of 
the neck of the femur in those instances in which the broken 
surfaces are held together in perfect and close contact by the 
untorn periosteum or by impaction. 

2. Bony union may occur in cases in which the line of 
fracture is partly within and partly without the capsular 
ligament, since in these cases displacement of the fragments 
is not likely to be great, the upper fragment is more fixed in 
position by reason of the attachments of the capsular liga- 
ment, and the fragments after adjustment can be more 
readily retained in position by dressings. 

3. In cases in which a separation of the fragments has 
taken place, ligamentous union or non-union occurs, owing 
to the great difficulty, in the majority of cases, of adjusting 



232 FRACTURES. 

the fragments in perfect contact, and, by the ordinary 
methods of treatment, retaining them in such position for a 
sufficient length of time. In these cases bony union may 
occur if, by any plan of treatment, perfect coaptation and 
immobilization of the fragments can be obtained. 

Treatment Owing to the dangers incident to the long 

confinement in bed of elderly and enfeebled persons in whom 
intra-capsular fractures most frequently occur, the treatment 
has largely been expectant in character. Tliis plan consists 
in placing the patient in bed with the limb flexed and 
secured over a double-inclined plane of the ordinary pattern, 
or over one formed of pillows. After two weeks he is per- 
mitted to get up and sit on a high chair, and shortly after- 
wards allowed to walk with the aid of crutches. In cases 
treated in this manner ligamentous or non-union occurs, the 
neck becomes siiortened by absorption, and rounded, the 
surface is covered with a porcelain-like deposit, and plays in 
a cavity formed by absorption in the head. The weight of 
the body is supported by the capsular ligament and the obtu- 
rator externus muscle, both of which become very much 
thickened. 

Impacted fractures treated by the above plan may result 
favorably, provided too much manipulation is not practised 
in arriving at a diagnosis, and great care is exercised during 
ten or twelve weeks after receipt of the injury in the use 
of the limb in locomotion. 

It is desirable in all cases to make an effort to secure 
bony union, and to accomplish this, treatment of a more 
positive character should be instituted. Reduction having 
been effected and extension maintained, a bandage should 
be applied, beginning at the foot and terminating by a 
double spica of the groin, with a broad and rather thick 



FKACTUKES. 233 

compress placed beneath it over the great trochanter of the 
broken bone so as to exert lateral pressure. Before the 
application of the roller the stirrup, made of adhesive plas- 
ter, is to be adjusted as represented in Fig, 96. The limb 
is now to be placed in the straight position, and after the 
expiration of six to eight hours the weights sufficient to 
maintain proper coaptation should be attached. The 
weights may consist of brick, weighing each five pounds, 
scale weights, bags containing shot or sand, or a bucket of 
water, the weight of which can be readily increased or 
diminished by the addition to or removal of the water. 
Additional support may be afforded by the application of 
bags of sand to the sides of the limb ; the one on the outer 
surface to extend from the foot to a slight distance beyond 
the crest of the ilium ; the one on the inside to reach the 
perineum. 

Careful attention should be given to the preparation of 
the bed, and proper provisions should be made for evacu- 
ation of the bowels as described on page 129. The general 
health of the patient should be closely watched, and tonics 
and nutritious diet given to maintain strength. If the 
patient's condition remains good the treatment should be 
continued for a period of three and one-half to four months. 
If evidences of the decline of the patient's strength or the 
formation of bed-sores present themselves, treatment in this 
form should be abandoned and the patient placed upon the 
sound side in an easy position with the limbs flexed. As 
soon as the strength will permit, the patient should, after the 
application of a suitable bandage, leave the bed and recline 
in an easy chair, and later take exercise on crutches in the 
open air. 

In a very elaborate and exhaustive paper on " Fractures 
20* 



234 



FRACTURES. 



of the Neck of the Femur," read before the American 
Surgical Association, and published in the first volume of 
its Transactions, Dr. N. Senn, of Milwaukee, attributes the 
bad results which follow after intra-capsular fracture as due 
more to the insufficiency of the treatment employed than to 
the anatomico-pathological conditions of the broken bone. 
He states " that all of the various methods of treatment sug- 
gested and practised have failed in securing perfect coapta- 
tion and uninterrupted immobilization. In all intra-capsular 
fractures union is effected by the production of an inter- 
mediate callus from the broken surfaces. Nature's splint, 

Fiff. 12P. 




the external callus, for well-known anatomical reasons, is 
always absent, hence the surgeon's splint has a more im- 
portant and prolonged application than in fractures in other 
localities." 



FRACTURES. 



235 



The time estimated for bony union to take pUace is from 
80 to 100 days, and treatment should be maintained for at 
least that period. In impacted fracture no attempts should 
be made to change the position in which the bone has been 
placed by the accident on account of the danger of loosening 
the impaction. Permanent fixation should be accomplished 
by the plaster-of-Paris bandage, which should be applied so 
as to include the injured limb from the toes upward, the 
entire pelvis, and the sound limb from the pelvis to the 
knee. The method by which suspension of the body is 
effected and extension maintained during the application of 
this bandage is shown in Figs. 129 and 130. Tin or 

Fitr. 130. 




wooden splints can be incorporated in tiie plaster dressing to 
give more support. Great care should be taken to prevent 
undue pressure on all prominent bony projections by the 
interposition of compresses. A flannel bandage should be 
applied next the skin. With this dressing the patient 



236 



FRACTURES. 



can leave the bed in a few days, and in a few weeks walk on 
crutches. Re-dressing should not be made until the expi- 
ration of the fifth or sixth week, and not then unless indi- 
cations are present demanding it. 



Ficj. 131. 



Fig. 132. 




FRACTURES. 237 

In non-impacted fractures, Dr. Senn advises in addition 
to tlie plaster bandage, lateral pressure to maintain coapta- 
tion by means of a pad to be adjusted by a screw, applied 
over the trochanter major, through a fenestrum made in the 
splint (Figs. 131 and 132). In certain favorable cases he 
further advises direct fixation of the fragments, which is to 
be accomplished by subcutaneous drilling of the neck of the 
femur and nailing the fragments together by means of a 
bone-peg, as has been done in the treatment of ununited 
fractures. The principles of treatment enunciated by Dr. 
Senn are, without question, correct, and their application 
deserves a trial at the hands of surgeons in the treatment of 
these fractures, which have heretofore been so largely given 
over to the expectant plan. 

Extra-Capsl'Lar Fractures — In extra-capsular frac- 
tures the line of separation varies in direction ; in some 
instances it is oblique, following the inter-trochanteric line, 
and in others transverse to the long axis of the bone, through 
the upper portion of the trochanter major. In still other 
instances comminution may occur with more or less impac- 
tion of the fragments. The line may extend within the 
capsule forming a mixed variety partly within and partly 
without the capsule. Cases of marked impaction occur in 
which the neck is forced into the upper portion of the shaft 
between the trochanters. 

Causes Fractures without the capsule are, as a rule, the 

result of violence applied directly over the great trochanter; 
it may occur from force applied indirectly, as falls upon the 
foot or knee. 

Symptoms The symptoms of extra-capsular fractures are 

usually well marked and are the same as those which attend 
fractures generally. The pain is very severe and superficial 



238 FRACTURES. 

in character, involving the tissues about the trochanters and 
much increased in intensity on motion. Swelling is gene- 
rally prominent, and the surface is discolored owing to the 
hemorrhagic infiltration into the subcutaneous tissue. Loss of 
function varies in different individuals, and is usually more 
pronounced than in the intra-capsular variety of fracture. 
Deformity manifests itself in shortening of the limb, which 
takes place promptly, with, in most cases, eversion of the foot; 
inversion may occur, as in some instances of intra-capsular 
fractures. The shortening varies from a half of an inch to 
two inches. Crepitus is very distinct, and can be easily felt 
and heard. In impacted fractures this symptom is absent 
unless undue violence is used to provoke it. The position 
and ranore of movement of the orreat trochanter varies in 
accordance with the line of fracture. Its range of move- 
ment may be but slightly affected on motion of the limb, or 
it may remain motionless, indicating, in this event, its de- 
tachment from the shaft. 

Diagnosis. — Careful study of the symptoms presented in 
extra-capsular fracture of the femur will usually enable the 
surgeon to arrive at a correct diagnosis, although, in some 
instances, the effort may be attended with difficulty. The 
symptoms of intra-capsular fracture and of dislocation of the 
head of the femur upon the dorsum of the ilium, are to be dis- 
tinguished from those of extra-capsular fracture by careful 
examination of those symptoms most prominent. For the 
purpose of convenient study, and to impress upon the mind 
the characteristic features of each, they are presented in a 
table, as follows : — 



FRACTURES. 



239 



Intra-capsular Frac- 
ture. 

1. Age ; over 50 years. 

2. Sex ; occurs most 
frequently in females. 

3. Cause ; slight ; force 
usually indirect. 

4. Pain ; not very se- 
vere ; felt deep in inner 
surface near to trochan- 
ter minor. 

5. Position of foot, 
everted. 

6. Shortening ; gener- 
ally not marked at first; 
increases gradually; from 
I to 1 inch; disappears 
under extension, and re- 
turns on removal of ex- 
tending force. 

7. Mobility very mark- 
ed. 

8. Crepitus indistinct. 

9. Disability marked. 
10. Result : Permanent 

disability. 



I ExTR.\-CAPStrLAR FRAC- 
I TCRE. 

1. Under 50 as a rule. 

2. No distinction. 

3. Force greater and 
direct. 

4. Severe ; superficial 
in character ; over great 
trochanter. 



5. Everted. 

6. IJsually prompt in 
occurrence ; from ^ inch 
to 1 or 2 inches ; reduced 
by extension, and returns 
on discontinuance of 
force. 

7. Very marked. 

S. Very distinct. 

9. Very marked. 
10. Disability much less 
— in some cases only tem- 
porary. 



Dislocation on Dorsum 
OF THE Ilium. 

1. Young and adult 
age. 

2. Most common in 
males. 

3. Violen<;e severe. 

4. Not severe. 



5. Inverted. 

6. From H to 2 inches ; 
disappears permanently 
on reduction of the dislo- 
cation. 



7. Limb fixed and im- 
mobile. 

8. Absent. 

9. Very marked. 

10. Disability ; relieved 
after reduction. 



It should not be forgotten that as the result of a contusion 
or a severe strain of tlie hip-joint a slow absorption of the 
neck of the bone may take place, producing shortening as in 
fractures involving the neck. Attended with rheumatic or 
traumatic inflammations these interstitial changes may be 
accompanied likewise by pain and crepitation. In all cases 
in which the nature of the injury is doubtful the patient 
should be informed of the results which may follow injury 
to the joint, without a fracture of the bone being present. 

Prognosis. — The violence inflicted at the time of the pro- 
duction of the fracture is sufficient in some instances to 
seriously complicate the case and to cause fatal results. In 



240 FRACTURES. 

ordinary cases the reparative process takes place promptly 
and without complications. Bony union occurs as in other 
parts of the shaft ; non-union may occur as the result of 
excessive inflammatory action, and in some instances enor- 
mous masses of callus are deposited about the seat of 
fracture. More or less disability follows extra-capsular 
fracture, where great comminution has occurred ; this con- 
dition is inevitable and is frequently very great. In im- 
pacted fractures efforts should not be made to correct the 
deformity which is present, unless it should be so great as to 
render the limb valueless in its abnormal position. 

Treatment. — The treatment of extra-capsular fractures is 
in general the same as that employed for those occurring 
within the capsule. The limb should be placed in the 
straight position and extension made by weights, with bags 
of. sand placed on either side to afford lateral support. 
Counter-extension should be made by elevating the foot of 
the bed. If the fracture is impacted weights sufficient only 
to maintain the limb in the extended position should be 
applied. 

The treatment of this form of fracture may also be con- 
ducted by means of the long external, with the short internal 
wooden splint, which should be well padded so as to avoid 
undue pressure. The modified Desault's apparatus affords 
an advantageous dressing of this kind. Junk-bags a.re 
placed on the inner surfaces of the splints to relieve pressure. 
Extension is made by fastening the foot by means of a 
bandage to the foot-piece attached to the lower end of the 
external splint, while counter-extension is effected by the 
perineal band secured to the upper end, or by an adhesive 
strip attached to an iron rod which extends from the upper 
end of the long splint over the front of the patient's shoulder 



FRACTURES. 



241 



and is held in position by strips of plaster applied around 
the chest. In the treatment of this fracture suspension ot 
the limb by means of Smith's anterior splints affords a very 
effective and at the same time a very comfortable form of 
dressing. The principle upon which the splint is made 
is that of the double inclined plane, and in using it the 
adjustment of the fragments is maintained by position 
and not by any efforts at extension. It consists of two 
parallel rods of wire held together by cross-pieces, and is 
fashioned in the shape of the double inclined plane. (Fig. 
133.) Before application it should be wrapped with a 

Fi-. 133. 




bandage and bent at such angle as to conform to the injured 
limb. At the ankle and groin where the turned-up extremi- 
ties come in contact with the surface, thick compresses 
should be interposed to prevent undue pressure. Adjust- 
ment of the fragments having been accomplished, the limb 
is carefully supported and the splint is applied to the anterior 
surface and held securely in position by turns of the roller 
beginning at the toes, and terminating about the pelvis. A 
coating of starch or solution of the silicate of sodium will fix 
21 



242 



FRACTURES. 



the roller in position. The hooks to which the suspension 
cord is fastened should be attached above and below so as 
to afford equable support, the upper one at the junction of 
the lower with the middle third of the thigh, or over the 
seat of the fracture if not too high, and the lower at the 
junction of the middle with the lower third of the leg. 
(Fig. 134.) The suspension cord should pass through a 




pulley attached to a crossbar supported by strong uprights. 
In the treatment of fractures of the lower extremity at any 
point, suspension of the limb gives great comfort to the 
patient and permits cautious movements of the body with- 
out endangering the adjustment of the fragments, the limb, 
swinging from the point of its suspension, follows the 
movements of the body without resistance. 

Great Trochanter Fracture of the great trochanter, 

as an independent lesion, occurs very infrequently. Tlie 
upper portion may be broken off, or it may occur as a sepa- 
ration at the epiphyseal line. 



FRACTURES. 243 

Cause. — Great violence, applied directly over the tro- 
chanter, is requisite to detach it from the shaft, such as that 
sustained in falls, or blows. 

Symptoms The symptoms resemble to some extent 

those present in fractures of the neck of the femur. One, 
which may be regarded as characteristic, is the inability of 
tlie patient to sit down, the increase of pain being so great 
as to compel a discontinuance of the effort. Eversion of 
the limb is present. Crepitus may be elicited^ but it is dif- 
ficult to accomplish owing to the wide separation of the 
fragments. Pain and swelling are usually present as the 
result of the injury to the surrounding parts. 

Diagnosis — The absence of any peculiar symptoms 
renders the diagnosis, in most cases, difficult. The removal 
of the prominence formed by the trochanter and the exis- 
tence of a sulcus or depression in its place is diagnostic. 
The evidence is more positive when the detached fragment 
can be grasped and brought in apposition with the shaft so 
that crepitus may be elicited. This effort may be assisted by 
strongly abducting the limb and fixing the upper fragment. 
Shortening of the limb, if present at all, can only exist to a 
slight degree. Separation at the epiphyseal line may occur 
in persons under twenty years of age ; the trochanter is 
united to the shaft by bone at or about that time of life. 

Prognosis. — The injury inflicted upon the parts at the 
time of the occurrence of the fracture is sometimes followed 
by grave constitutional disturbances and later by excessive 
suppuration. Non-union of the fragments or ligamentous 
union occurs. Partial ligamentous and partial bony union 
have been observed in some cases. Disability more or less 
permanent in character is liable to follow. 



244 FRACTURES. 

Treatment — Efforts should be made by abduction of tlie 
limb, to approximate the fragments and to retain them in 
apposition by means of compresses and broad bandages or 
broad strips of adhesive plaster. A broad leather belt, with 
a hollow pad to apply over the prominence of the hip, as 
recommended by Sir Astley Cooper, may be applied to 
accomplish the same result. Immobility of the affected 
limb should be effected by wooden splints placed on the 
inside and outside. Extension is not required. 

Shaft Fractures of the shaft of the femur may occur 

either in the upper third, middle, or lower third — the most 
frequent seat of fracture is the middle of the bone. The line 
of separation is, as a rule, oblique, and varies in position in 
different parts, being generally downward and inward in the 
middle, and downward and forward in the lower third. 

Causes Violence, applied directly or indirectly, may be 

the cause of fracture of the shaft. Direct force may be ap- 
plied by the passage of the wheel of a heavily ladened wagon 
or car, the crush by the fall of a mass of earth, or a heavy 
piece of timber. Indirect force may be applied by falls from 
a height upon the foot or knee. I have now, under my care 
at St. Mary's Hospital, a lad seventeen years of age, who 
sustained a very oblique fracture of the femur in the upper 
third by a fall upon his feet through a hatchway, precipi- 
tating him the distance of nearly fifty-feet. Cases are re- 
corded in which fracture of the shaft has been produced by 
muscular action. 

Symptoms — The symptoms of fracture of the shaft of the 
femur are well marked, and consist of those which attend 
fractures generally, as pain, loss of function, preternatural 
mobility, deformity, and crepitus. 

Diagnosis The diagnosis is usually made without diffi- 



FRACTURES. 245 

ciilty, owing to the distinct character of the symptoms. 
Crepitus can be elicited by rotation of tlie limb after bring- 
ing the fragments into apposition by extension. 

Prognosis In simple fractures the prognosis is favorable 

with regard to union. In compound, and especially in com- 
pound comminuted fractures, extensive suppuration with 
necrosis of bone may occur, retarding the reparative process 
and terminating sometimes in non-union. An excessive de- 
posit of callus may surround the seat of fracture, giving rise 
to deformity. More or less shortening of the limb is liable 
to follow in all cases. Especially is this true with regard to 
fractures in which the line of separation is in the oblique 
direction. The shortening varies from one-half to three- 
quarters of an inch — in some cases it is much greater, reach- 
ing two inches or more. It is the general opinion of surgeons 
of experience that it is impossible in some cases to obtain a 
better result, and a cure of an ordinary oblique fracture of the 
femur in which the shortening of the limb is from one-half to 
three-quarters of an inch is regarded as. in every respect, a 
successful termination. In a strictly transverse fracture, in 
which the fragments are accurately apposed and retained in 
such position, very little, if any, shortening should occur ; 
such fractures are, however, of rare occurrence. The shorten- 
ing which occurs in oblique fractures is to be explained by 
the action of the powerful muscles of the thigh, wiiich is 
antagonized by the resistance offered by the large and strong 
bone whilst intact. It is difficult to adjust accurately the 
oblique surfaces, more or less irregular, and to completely 
overcome in the treatment the contraction of the muscles. 

Treatment — Fractures of the shaft of the femur may be 
treated with the limb in one of two positions — straight or 
semi-flexed. 

21* 



246 FRACTURES. 

Treatment in the Straight Position The dressings whicli 

have been employed for the purpose of retaining the frag- 
ments in apposition during repair have varied very much in 
form and character from the earliest day to the present time. 
Those used consisted at first of cumbersome wooden splints 
applied to the lateral surfaces of the limb. In some forms 
they were applied to both the sound and injured sides, 
extending from the feet to the axillse, inclosing the patient, 
as it were, in a box. To obviate the great difficulties 
encountered in securing extension and counter-extension, 
without producing undue pressure, and in the long axis of 
the body, modifications were from time to time devised. 
These related chiefly to the adaptation of foot pieces to ob- 
tain extension, and increase in the length of the external 
splint, or change in the form of the perineal band or upper 
extremity of the short internal splint, to avoid the pressure 
exerted over the perineum and to accomplish counter-exten- 
sion in the long axis of the limb. Anterior splints were 
employed in some varieties of apparatus to prevent anterior 
displacement of the fragments. Splint-cloths were used to 
wrap about the splints, and junk-bags were placed between 

Fis. 135. 



WTffi'Wimmmmmm0'^W0M^WT~ 



the splints and surface of the limb to prevent pressure, as 
in Liston's splint (Figs. 135, 136). The late Prof. Gross 
employed a fracture-box, extending from the tuberosity of 
the ischium to a level with the sole of the foot, which rested 



FRACTURES. 



24; 



against a vertical foot-piece. 
Attached to each side was a 
movable splint with a crutch- 
shaped upper extremity, the 
one on the outside extended 
to the axilla, while that on the 
inside was designed to press 
against the perineum. 

When properly applied the 
wooden splints formed quite 
firm supports and maintained 
the parts at rest, but they were, 
in many instances, very awk- 
ward and unwieldy, liable to 
produce excoriations by pres- 
sure on the perineum and at 
other points, and to become 
disarranged easily. To inspect 
the seat of fracture it was ne- 
cessary, in some of the various 
forms, to remove the entire 
dressing, and thus incur the 
danger of a disturbance of the 
fragments. 

On the introduction of the 
pulley and weight for the pur- 
pose of making extension, and 
the elevation of the foot of the 
bed to obtain the counter-ex- 
tending weight in the body of 
the patient, a great advance 




248 FRACTURES. 

was made in the treatment of fractures of the femur in the 
straight position. By this plan extension is made in the long 
axis of the body by means of a stirrup, formed from adhesive 
strips, which is secured to the limb by circular strips. The 
strips of adhesive plaster forming the stirrup should extend 
on the outside and inside of the limb to a point just below the 
seat of fracture, and should be of equal length. They should 
always extend beyond the knee-joint, so as to avoid traction 
upon this joint. The dressing is prepared and applied in 
the following manner: The limb having been washed, and, 
if necessary, deprived of hair, is placed in the extended 
position, and a strip of adhesive plaster, two and one half 
inches wide is applied on both sides of the limb so as to 
extend from a point just below the seat of fracture to the 
level of the sole of the foot under which the loop of plaster 
passes. A block of thin wood as wide as the strip of plaster, 
and from four to five inches long, with a hole in the centre, 
is placed in the loop of plaster and held by a short strip of 
plaster ten inches long, witli the middle portion four to five 
inches wide, and the ends two and one-half inches in width 
(Fig. 93). The middle portion of this short strip is placed 
on the inner surface of the block, the edges being lapped 
over, and the ends applied to the inner surface of the long 
strip extending opposite the position of the malleoli (Fig. 95). 
This short strip of plaster not only fixes the block in posi- 
tion, but also prevents the plaster from adhering to the 
malleoli. Tiie extension band is fastened to the limb by 
three strips of plaster applied in a circular manner, one 
above the ankle, one below, and one above the knee 
(Fig. 96). A cord, firmly knotted, is passed through the 
opening in the centre of the foot piece. Extension and 
counter-extension being now made, so as to accurately 



FRACTURES. 



249 



adjust the fragments, a roller is applied ^r/??/?/ but carefully, 
beginning at the toot, and terminating beyond the seat of 
fracture. Bags of sand are now to be placed on the outside 
and inside of the limb, that on the outside to extend to the 
crest of the ilium, and that on the inside to the perineum. 
The bags should not be too full, as this will prevent moulding 
them to the inequalities of the surface, and interfere with 
the accomplishment of equable pressure. After raising the 
foot of the bed from four to six inches to obtaia counter- 
extension, the limb should remain at rest from six to eight 
hours until the muscular spasm has measurably subsided, 
and the plaster extension band has secured firm attachment 
to the surface ; at the expiration of this time the weight, 
which should be sufficient to maintain the fragments in appo- 

Fi-. 137. 




sition, should be fastened to the cord, passed over the pulley 
(Fig. 137). The amount of weight required to overcome 
the muscular contraction will vary in different cases. In a 
patient of powerful muscular development more weight will 



250 FRACTURES. 

be required than in one of slight muscular power. If it is 
found at the expiration of two days tliat the weight is not 
sufficient to prevent overlapping of the fragments and main- 
tain them in proper apposition more should be added. In 
the adult male usually ten to fifteen pounds, represented in 
two or three bricks of five pounds each, are sufficient. The 
upright support for the pulley may be arranged as shown in 
Fig. 94, or it may be attached to the foot of the bed (Fig. 137). 
The latter plan is better, as the support is more fixed and 
less liable to be displaced. If there exists much tendency 
to anterior displacement of the upper fragment, a short 
splint well padded can be placed over the surface beneath 
the roller. Dr. Gurdon Buck, of New York, surrounded 
the seat of fracture with four short splints, held together by 
two leather bands, provided with buckles to fasten them 
about the limb. The object of this splint was to keep the 
fragments more securely in apposition. Modifications of the 
apparatus for extension by weights and pulleys are found in 
the apparatus of Dr. Morton (Fig. 138). 

The treatment of fractures of the shaft of the femur by 
means of the weights and pulleys, with the lateral support 
derived from the use of bags of sand, affiards the most satis- 
factory results. The simplicity of the apparatus, and the 
ease with which it is prepared and applied should commend 
it to the surgeon. 

In addition to the dressings above described, which are 
employed in the treatment of fractures of the shaft of -the 
thigh in the straight position, is that made by the application 
of the plaster-of-Paris bandage. The apparatus used for 
the suspension of the patient during the application of the 
bandage is shown in Fig. 129, and consists of a table, to 
which is screwed an upright stanchion with a cross-bar 



FRACTURES. 



251 



attached. The nates and lower part of the trunk are sup- 
ported in a broad sling \Yhich is suspended from the cross- 
bar. The body is brought down so that the perineum rests 
against the upright stanchion, which is well padded to pre- 




vent undue pressure, and extension is made by a pulley fas- 
tened to the ankle and foot. Reduction having been effected, 
the limb is incased in a tight-fitting, woollen or flannel cover- 
ing, and the plaster bandage is applied as directed on page 
109. The extension should be maintained until the plaster 
has hardened so as to preserve the coaptation of the frag- 
ments. Tlie patient is placed in bed, where he remains for 
a few days, and then is permitted to get up and walk on 
crutches. After the application of the plaster bandage care- 
ful attention should be given to the condition of the limb 
and of the bandage. Examinations should be made fre- 
quently to ascertain the state of the circulation of the limb, 



252 FRACTURES. 

as the pressure exerted by the bandage, owing to the swell- 
ing, raay seriously interfere with it, even to the production 
of gangrene. On the other hand, the subsidence of the 
swelling may leave the bandage so loosely applied as to 
permit displacement of the fragments. Tlie great advantage 
derived from the use of plaster bandage consists in the 
release of the patient from confinement in bed. 

Treatment in the Semi-flexed Position — The treatment of 
fractures of the shaft of the femur in the semi-flexed position 
is accomplished by means of the double inclined plane or 
modification of this appliance. The apparatuses of Mclntyre, 
N. R. Smith, and Hodgen are modifications of the double-in- 
clined plane. Fig. 139 exhibits the double-inclined plane 

Fig. 139. 




combined with the fracture-box. In this method of treatment 
the muscular contraction is largely overcome by position of 
the limb. After reduction of the fracture, a roller is applied 
to the limb, and two splints of binder's board, reaching 
from the groin to the knee, are applied to the outer and 
inner surface of the tliigh and moulded to the parts. The 
limb is now placed upon the inclined plane, on which two 
grooved cushions have been previously fastened and secured 
in position by turns of a roller. In some instances it is 
desirable to combine extension by pulleys and weights with 
the semi-flexed position of the limb over the double inclined 



FRACTURES. 253 

plane as recommended by Prof. Agnew. When this is done 
the plaster stirrup is attached to tlie thigh alone. Lateral 
pressure is effected by raising the sides of the femoral part 
of the combined plane and fracture-box and securing them 
in place by turns of a bandage. 

In the treatment of fractures of the upper third or in the 
lower third of the femur above tlie condyles, the semi-flexed 
position secures, in many instances, better adjustment of the 
fragments than can be obtained in the straight position. In 
compound fractures the position sometimes affords the patient 
more comfort than when the limb is extended. 

Several points demand careful consideration in conducting 
the treatment of fractures of the shaft of the femur. 

1. Great care should be given to the preparation of the 
bed upon which the patient is compelled to rest for a period 
of time. 

2. Careful inspection of the seat of fracture should be 
made from time to time in order to ascertain the position of 
the fragments ; if any tendency to displacement exists it 
should be corrected at once by such means as may be neces- 
sary ; if possible, shortening should be prevented ; if not 
preventable it should be reduced to the minimum. 

3. All parts subjected to pressure by the dressings or 
otherwise should be frequently examined in order that 
timely effort may prevent excoriations. Careful attention 
should be given to the condition of the nates, perineum, if 
pressure is exerted upon this part, and the heel. 

4. If the limb is treated in the straight position, and by 
extension and counter-extension, the head and shoulders of 
the patient should be kept low, a small pillow only being 
used ; in some cases even that may be dispensed with. 

5. Compound fractures of the sliaft of the femur require, 

22 



254 FRACTURES. 

in the treatment, tlie use of a bracketed splint in order tliat 
the wound may be readily exposed without disturbance of 
the fragments. The long fracture-box containing bran may 
be employed with advantage, or the immovable dressing, 
in which a fenestrum has been made, over the site of the 
wound. 

6. In children old enough to comprehend the instructions 
of the surgeon and attendants the dressings used for adults 
may be employed. In very young children, or in those 
difficult to control, the dresvsings should be made immovable 
and so arranged as to keep the patient in the recumbent 
position, in order that the movements of the body may not 
disturb the fragments. A form of dressing best adapted 
consists of a long external splint extending from a point 
near to the axilla to two inches below the sole of the foot. 
To insure quietude during the application of the dressing an 
antesthetic should be administered. The fragments having 
been adjusted and extension maintained, a roller is applied 
terminating in the spica of the groin. Projecting bony 
prominences, as the crest of the ilium, the external condyle 
of the femur, and the external malleolus, should be pro- 
tected by masses of cotton-wool, and the splint, well padded, 
should be placed alongside of the limb and secured in posi- 
tion by turns of tlie plaster or silicattf of sodium bandage. 
If the latter is used, it is desirable to apply over the seat of 
fracture strips of binder's board or tin to give additional 
support, and, at least, three rollers, each being covered with 
the solution. The upper part of the splint should be 
secured to the body by spiral turns of a plain roller. The 
plaster bandage should be covered with a coat of varnish in 
order to protect it from the effect of the discharges and 
insure cleanliness by washing the surface. The silicate 



FRACTURES. 255 

bandage is of itself impervious to fluids and can be washed 
without ufll'ecting its firmness. 

Instead of the external wooden splint, the late Prof. Gross 
employed a splint made of stout unoiled sole leather, which 
was moulded about tlie limb, beginning around the hip and 
extending an inch and a half below the foot, at which point 
a suitable foot-piece was attached. On the anterior surface 
of the thigh a splint of leather or binder's board, reaching 
from the groin to the knee, was placed, and after protecting 
the parts with compresses of cotton-wool, the whole was 
secured in position by a roller. The foot was fastened to the 
foot-piece by strips of adhesive plaster. Frequent inspec- 
tions of the dressings employed in the treatment of fractures 
of the femur in children are requisite in order that any 
displacements, whicli are quite liable to occur in them, may- 
be corrected at once. 

7. The time required for union after fracture of the shaft 
of the femur varies at the different periods of life, and is 
influenced by the condition of health of the patient and 
the manner in which the treatment has been conducted. In 
children consolidation takes place, under favorable circum- 
stances, in three or four weeks. In adults a longer period is 
required, from five to six weeks. The patient should not be 
permitted to use the limb in supporting the weight of the 
body under ten or twelve weeks. Neglect of this precaution 
may lead to the occurrence of shortening owing to the 
absence of firmness in the callus which has been formed. 

In cases treated by extension the weights should be with- 
drawn gradually, and the limb enveloped in a firm bandage. 
On removal of the dressings the patient should rest in bed 
for a day or two before making an effort to occupy the sitting 
posture. Locomotion should be accomplished at first with 



256 FRACTURES. 

the aid of crutches. In some instances it is desirable to 
apply the silicate bandage in order to afford more support to 
the limb. 

Condyles Fractures of the condyles may occur through 

the base, separating them from the shaft, or one, and in rare 
instances both, may be detached by a vertical line of separa- 
tion. Separation at the epiphyseal line may occur in persons 
under twenty years of age. 

Causes. — Fractures involving the condyles are usually the 
result of great violence applied directly, as a fall from a 
height upon the knee, the kick of a horse, or a violent 
\Yrench of the limb, the foot and leg being fixed. 

Symptoms The swelling which supervenes rapidly in 

fractures at this point has a tendency to mask the symptoms. 
Great pain is experienced on any effort at movement, and 
the function of the limb is lost. With the exception of a 
marked increase in the width of the knee there is very little 
deformity. Where displacement of the fragments exists the 
deformity is more apparent. Shortening is usually not well 
marked, unless both condyles are broken, when it may occur 
to the extent of one or two inches. Crepitus can be elicited 
in most cases by manipulation. 

Diagnosis As in all cases of fracture near to or involv- 
ing a large joint, the diagnosis is surrounded with more or 
less difficulty. On account of the swelling which accom- 
panies the injury very imperfect examinations only can be 
made. Severe contusions of the joint, especially when associ- 
ated with dislocation, are accompanied by symptoms which 
resemble, in some respects, those of fracture of the condyles. 
If the injury is compound in character, the wound may be 
explored by the finger, and the nature of the fracture deter- 
mined. Crepitus is difficult to detect ; deep pressure may 



FKACTURES. 2o/ 

enable the surgeon to move tlie broken fragments. Exam- 
inations should be made after the subsidence of the swelling, 
if any doubt exists as to the nature of the injury. It is a 
matter of much importance that the diagnosis should be 
accurately made, in order that the proper plan of treatment 
should be adopted. 

Prognosis The dandier of involvement of the knee-joint, 

primarily or secondarily, renders the prognosis unfavorable. 
"When the fracture is through the base of the condyles, the 
fracture-producing cause is very liable to inflict such injury 
upon the joint as to involve it seriously. In fracture of one 
or both condyles the joint is directly implicated, and asso- 
ciated with the fracture, the surgeon must deal with all of 
the grave conditions which attend intlammation of the struc- 
tures of a large joint. In compound and complicated frac- 
tures the dangers are greatly increased, and the question of 
amputation presents itself for serious consideration." Under 
the most favorable conditions more or less swelling and stiff- 
ness of the joint are liable to follow, and in complicated cases 
anchylosis will occur, despite the most skilful treatment. 
In some rare instances of fracture at tlie base of the con- 
dyles the upper fragment is drawn down behind the lower, 
and exerts dangerous pressure upon the important blood- 
vessels occupying the popliteal space. As a result of this 
pressure, gangrene of the leg and foot may occur. 

Treatment. — The preliminary treatment in fractures in- 
volving the condyles must be antiphlogistic in character, 
owing to the inflammatory conditions which almost in- 
variably accompany the injury. The application of leeches 
and evaporating lotions should be made. Under the influ- 
ence of an anaesthetic agent reduction should be effected. 
Sometimes this is best accom[>lished by flexing the knee and 

22* 



258 



FKACTL'KES. 



making extension, with the forearm in the popliteal space. 
Where comminution has taken place, manipulation should 
be employed to mould the fragments into position. After 
reduction, if it is found that there is little or no tendency to 
displacement, the limb may be treated in the straight posi- 
tion with w^eights and sand-bags. In very oblique fractures 
it will be found sometimes that adjustment can be better 
maintained with the limb in a flexed position, over a double- 
inclined plane. In compound fractures Packard's bracketed 
splint (Fig. 140) should be used in order that the wounds 

Fiff. 140. 




may receive attention without disturbance of the limb. An- 
tiseptic dressings, with careful drainage, should be employed 
in order to avert the dangers attending extensive suppuration 
in the joint. Passive motion may be instituted at the expi- 
ration of the fourth or fifth week, when consolidation is suffi- 
ciently advanced. When anchylosis is inevitable the limb 
should be placed in a slightly flexed position, in order that 
the patient may walk with comfort and with but little lame- 
ness by wearing a high-heeled shoe. 



VKACTURES. 259 

Patella. — In discussing fractures of this bone, it is 
desirable, in order to comprehend fully the symptoms which 
attend them, as well as the indications for treatment, to 
consider its anatomical relations. An examination shows 
that the common tendon of the group of muscles forming 
the quadriceps extensor, passinjj^ from the anterior and lateral 
aspects of the thigh, is inserted into the superior and lateral 
borders of the patella, covering by an expansion of its fibres 
the anterior surface, and extending to the apex, to the under 
surface of which it is attached, then is continued as a broad 
strong band to its insertion in the tuberosity of the tibia, 
this portion being designated as the ligamentum patellae. 
With the exception of the internal surface, which is articular 
and covered with cartilage, the entire bone is enveloped in 
the fibres of the tendon, and becomes a part of the tendon 
as it w^ere. It may be stated, therefore, that the quadriceps 
muscle is inserted into the tuberosity of the tibia by an 
osseo-tendinous band, the bone being placed in the tendon 
for the purpose of affording protection to the knee-joint in 
front, and to increase the leverage of the extensor muscle. 
The bone being so much a part of the tendon, it is necessary, 
in considering fractures of it, to examine into the conditions 
which take place in the tendon. Fractures of the patella 
caused by muscular action are always accompanied by rupture 
more or less complete of the tendinous structures. In frac- 
tures due to direct violence, rupture of the tendon rarely 
occurs; when it does occur it is partial in character. In 
fractures which are the result of muscular action, the line 
of separation is transverse. Violence applied directly may 
produce fracture in the transverse, oblique, or vertical direc- 
tion. In fractures caused by muscular action the important 
point is to direct the treatment so as to secure firm and close 



260 FRACTURES. 

union of the torn tendinous structures, as well as of the frag- 
ments of the bone. The failure to maintain the permanent 
close union of the bony fragments obtained by treatment 
has been due, in my judgment, to the failure to secure suffi- 
ciently accurate approximation and contact of the torn edges 
of the tendon by the apparatus employed. 

Causes Muscular action or direct violence. The former 

may produce fracture in the violent effort to maintain the 
erect position when the body is thrown forcibly backward, 
the knee being, in the meanwhile, in a state of flexion. 
Direct force, as a kick from a horse, a blow with a bludgeon, 
or a fall upon the knee, may cause a fracture, the line of 
separation being either in the transverse, oblique, or vertical 
direction. Compound and comminuted fractures are the 
result of very severe violence or gunshot wounds. 

Symptoms. — In fractures caused by muscular action the 
symptoms are well marked. Those most prominent are loss 
of function and deformity. The patient may have heard 
-the snap produced by the fracture of the bone. He at once 
recognizes his inability to extend the limb in progression, 
the effort being usually followed by a fall. The deformity 
is caused by the swelling which ensues, and by the drawing 
up of the upper fragment, which forms a prominence at a 
greater or less distance above the knee, with a marked sulcus 
or depression over the anterior surface of the joint. The 
extent of separation of the upper from the lower fragment 
varies in accordance with the more or less complete rupture 
of the tendon. If the rupture is complete the contraction 
of the muscle may cause a separation of from two to four 
inches. Crepitus may be elicited by extending the limb so 
as to bring the fragments into contact. Usually this is diffi- 
cult, on account of the swelling which occurs. Pain is 



FRACTURES. 261 

sometimes quite marked, experienced more especially at the 
time of the receipt of the injury. In fractures produced by 
direct violence the injury to the joint is of such character 
as to render the symptoms more or less obscure. Pain is 
marked. The separation of tiie fiagments is much less, the 
deformity being caused largely by the swelling ; loss of 
function varies in accordance with the severity of the injury. 
Crepitus can be more readily detected, owing to the slight 
separation of tiie fragments ; in vertical and comminuted 
fractures it is readily obtained. 

Diagnosis In transverse fractures caused by muscular 

action the symptoms are so distinct as to render the diagnosis 
usually easy, especially if the examination has been made 
before the supervention of much swelling. Transverse frac- 
tures produced by direct violence are sometimes difficult to 
recognize by reason of the slight separation of the fragments, 
owing to the non-occurrence of rupture of the tendon. In 
oblique or vertical fractures, or where the bone is commi- 
nuted, crepitus may be readily distinguished. In compound 
fractures the wound can be explored with the finger and the 
condition determined. As little movement as is consistent 
with a thorough examination should be made, so as not to 
increase the separation of the fragments. 

Prognosis Fibrous union, with more or less separation 

of the fragments, and, as a result, with more or less disa- 
bility, is liable to follow transverse fracture of the patella, 
with rupture of the tendon, due to muscular action. In 
transverse fracture caused by direct violence, close union by 
fibrous tissue is frequently accomplished. Rare instances 
are recorded in which bony union has follow^ed transverse 
fractures produced by muscular action. The fragments in 
transverse fracture caused by direct violence, owing to the 



262 FRACTURES. 

non-rupture of the tendon, can be more readily approximaled 
and maintained in coaptation, and in this form bony union 
may frequently occur. The disability varies very much in 
different individuals. I have observed instances in which 
patients, M^ith wide separation of the fragments, apparently 
suffered no inconvenience, the full and free use of the limb 
being present. I have at this time a patient under observa- 
tion, who had sustained transverse fracture of both patellae, 
the result of muscular action, one fracture occurring a year 
subsequent to the other. Wide separation of the fragments 
exists, and the patient is liable to fall in walking rapidly. 
A peculiar form of disability accompanies this case, in that, 
while the patient is able to ascend the stairs naturally and 
without great effort, she is compelled, through the fear of 
falling, to descend backward. 

More or less weakness of the limb is liable to follow in 
all cases. This fact explains the liability to the subsequent 
occurrence of fracture in the same bone, as well as in the 
bone of the other limb. In cases of wide separation, the 
bond of union is formed between the upper borders of the 
fragments, and consists of the expansion of fascia covering 
the anterior surface of the bone, increased somewhat in 
thickness by inflammatory action. When the separation 
does not exceed one inch and a half, fibrous tissue is devel- 
oped between the ends of the fragments, filling up the space 
and forming a stronger connecting bond. 

Treatment. — The indications for treatment are to overcome 
by proper measures the inflammatory conditions which are 
very frequently present, and then to apply sucli dressings as 
will maintain the fragments in close contact until union takes 
place between their surfaces, and in transverse fractures, 
of the edges of the torn tendinous structures. In order to 



FRACTURES. 263 

remove the inflammatory conditions present, it may be 
necessary to deplete tiie parts by the application of leeches 
and to apply evaporating lotions subsequently. In some 
cases the effusion of synovial fluid is so great as to demand 
its removal by the aspirating needle. Collections of blood 
in the joint require to be removed in the same manner. It 
may be desirable to place the limb at rest for a period of 
time — from four to six days — while this treatment is being 
carried out, and before any permanent dressing is applied. 

A large number of appliances and dressings have been 
devised to maintain the fragments in proper coaptation. A 
few of them are effective, while a great number are not only 
not effective, but productive of bad results. In fractures 
due to muscular action, the limb should be placed in a com- 
plete state of extension upon a single inclined plane, with 
the body in the semi-erect position, so as to relax the quad- 
riceps extensor muscle, and the dressings should be applied 
in such manner as to hold the upper fragment, after being 
placed in accurate contact with the lower, firmly in place. 
Bearing in mind the attachment of the tendon of the extensor 
muscle to the entire border of the bone, as well as to its 
anterior surface, suitable pressure should be made over the 
sides and anterior surface to prevent tilting upward of the 
edge of the upper fragment, and folding and wrinkling of 
the tendinous structures. A simple and effective dressing 
fulfilling these indications was employed by the late Prof. 
Gross, and consists of a strong, well-padded tin or wire case, 
long enough to reach from the middle of the thigh to the 
middle of the leg. A bandage having been applied to the 
limb from the toes upward, stopping below the knee, and 
another beginning at the groin and carried as far as the 
middle of the thigh, the limb is then placed in the case. 



264 FRACTURES. 

The upper fragment having been brought into contact with 
the lower, is confined by numerous adhesive strips carried 
around the bone above and below the joint, and connected 
by vertical and transverse pieces. A long, thick, and rather 
narrow compress is now extended around the upper border 
of the patella, and is secured in place firmly by the two 
bandages, which are continued upward and downward, and 
surround the knee-joint by figure-of-8 turns. By means of 
this dressing the limb is held by the case in a state of exten- 
sion, the upper fragment is secured in place by the adhesive 
strips, and muscular action is controlled by the two bandages, 
applied in opposite directions. 

Prof. Agnew employs with success an apparatus consisting 
of a piece of pine board, somewhat convex longitudinally 
on the upper surface, thirty inches long, five inches wide 
above, and four inches wide below. Two holes are made on 
the sides, above and below the middle, to receive four pegs 
with square heads. The splint must be well-padded and 
placed beneath the thigh and leg, the limb being moderately 
elevated. Two or three strips of adhesive plaster, each 
thirteen inclies long and three-quarters of an inch wide, are 
applied below the lower fragment, partially overlapping each 
other. The ends of these strips are wrapped around the 
upper pegs. The upper fragment is held in position by five 
strips applied in like manner. The fragments are brought 
into contact by turning the pegs, and the tilting forward of 
the borders of the fragments is prevented by the application 
over the anterior surface of the bone of a broad strip of 
plaster, which is fastened to the splint below. The splint is 
secured to the limb by rollers applied above and below the 
knee (Fig. 141). 

Prof. Hamilton's apparatus consists of three pieces of board 



FRACTURES. 



265 



hinged together so as to form a single inclined plane with a 
foot-board. The piece for the limb is notched so as to hold 
securely the roller wliich envelops the knee. The plane 
having been padded, the limb is placed upon it, and the foot 



Fig. 141. 




at right^angles to the leg, is fastened to the foot-piece (Fig. 
142). The body is placed in the semi-erect position. 



so as 



'ig. 142. 




to assist in relaxing the quadriceps muscle. The preliminary 
treatment of the fracture consists in the application of a 
2o 



266 



FRACTURES. 



Fi-. 143. 



roller by oblique and circular turns above and below and 
over the knee, each turn passing through the notch. The 
limb is fastened to the splint by turns of the second roller, 
beginning at the ankle and passing over the knee by oblique 
and circular turns through the notch in the same manner as 
the first roller, and terminating at the groin. About the tenth 
day, the swelling having subsided, the permanent dressing, 
consisting of strips of adhesive plaster, may be substituted 
for the first or uniting bandage. Careful inspection of the 
parts should be made daily for some time, the retaining 
bandage being removed for that purpose, 
and reapplied carefully with increased 
firmness as the swelling disappears. The 
covering in of the entire knee by the turns 
of the bandages prevents the tilting up- 
wards of the edges of the fragments, and 
secures their perfect coaptation. 

Recognizing the difficulty, by other 
dressings, of securing accurate contact of 
the fragments and of preventing the ever- 
sion of their edges, Malgaigne devised his 
hooks (Fig. 143). They consist of double 
hooks, at each end of sliding plates con- 
trolled by a screw, by which they can be 
approximated or separated. The hooks 
are inserted into the tendon at its point of 
insertion into the edge of the patella above 
and below — they are so shaped that they 
cannot penetrate the bone or the joint. Before applying the 
hooks, preliminary treatment should be instituted, if neces- 
sary, to remove all inflammatory conditions. Although a 
few cases have been reported in which erysipelas and even 




FRACTURES. 267 

fatal results have followed the use of the hooks, many have 
been treated without any complications and with the best 
results. They should be employed, however, with caution, 
careful attention being given to the condition of the parts 
during the progress of the treatment. It is desirable to 
place the limb upon an inclined plane, with evaporating 
lotions applied over the knee, and permit it to rest in this 
position for a period of six to eight days before applying the 
hooks. At the time of application the integument should 
be drawn very tense so as to prevent tiie formation of folds 
and its consequent contusion by the instrument. Very 
little dressing is required. Around and between the hooks 
lint charged with carbolized oil may be packed. If there is 
undue action of the extensor muscle present, the body may be 
kept in the semi-erect position and the limb placed upon an 
inclined plane. To secure complete relaxation of the quad- 
riceps muscle, and as well quiet the fears of nervous patients, 
it is desirable to employ an anaesthetic at the time of the 
application of the instrument. Opinions differ as to the 
length of time required to keep the instrument in position. 
Some authorities state that they should remain from a period 
of six to eight weeks. Others believe that consolidation is 
effected in from two to three weeks. So long as they do not 
provoke irritation, it would seem desirable to permit the 
instrument to remain in position at least four weeks, and 
after its removal the knee should be covered by a firm 
bandage applied in figure-of-8 turns, and kept in a slightly 
elevated position. 

It is my belief that separation of the fragments has 
occurred in many cases, in which good approximation had 
been effected during treatment by permitting the patient to 
use the limb at too early a period after union. It matters 



268 



FRACTURES. 



not what form of dressing has been employed, the patient 
should be forbidden to use the limb in any effort under three 
ov four months. If stiffness of the joint has occurred as the 
result of confinement of the limb in the fixed position, or as 
the result of inflammatory action, passive motion should be 
employed very cautiously by the surgeon during this period. 
Drs. Levis and Morton of this city have used modifica- 
tions of Malgaiixne's hooks with orood results in cases treated 
at the Pennsylvania Hospital. Dr. Levis separated the 
original instrument into two hooks, while Dr. Morton modi- 
fied it so as to form a double triangle (Fig. 144j. The 



Fi^. 144. 




■^ 



objects to be accomplished by these modifications is the 
distribution of the pressure over a greater surface, and as a 
result the obtaining of more perfect coaptation. 

Besides the appliances above described, many have from 



FRACTURES. 



269 



time to time been devised and employed with varying success. 
The appliances of Lonsdale (Fig. 145) and of Boisnot (Fig. 

Fis. 145. 




146) are simple in construction, and act upon tiie same 
principle as those of Profs. Agnew and Hamilton. 



Fis. 146. 




In cases in which wide separation of the fragments has 
followed, despite of careful treatment, the disability conse- 
quent thereupon may be relieved by use of the apparatus 
devised by Messrs. D. W. Kolbe & Son, instrument makers, 
of this city (Fig. 147). 

Compound fractures of the patella are very grave injuries, 
and may be followed by fatal results by the supervention of 
inflammation of a severe form. If the inflammation involves 
the structures of the joints and passes on to tlie stage of sup- 
puration, the destruction of the joint is inevitable. The in- 
dications for treatment are eminently antiphlogistic in the first 

23* 



270 



FRACTURES. 



Stage, and tonic and supportive in tlie second. An effort 
should be made to convert, if possible, the compound nature of 
the injury into that of a simple one 
by closing the external wound. The 
limb having been placed on a bracketed 
splint (Fig. 140), antiseptic dressings 
should be applied, and on the occur- 
rence of suppuration, free incisions 
should be made, and complete drain- 
age should be accomplished by the in- 
troduction of drainage-tubes. The 
question of primary amputation, or of 
excision or amputation as a secondary 
operation, will present itself in many 
cases for serious consideration. In 
comminuted fractures all of the loose 
pieces should be removed. The value 
of antiseptic dressings is best shown 
in the treatment of injuries of this 
character. 

Leg — Fractures of the bones of 
the leg are of very frequent occur- 
rence owing to their exposed position and to the fact that 
the violence sustained in falls upon the feet is liable to 
be expended first upon these bones. Examinations of 
records and museum collections of specimens show that both 
bones sustain fracture more frequently than either the tibia 
or fibula alone, and that the level at which the separation 
ceours is not the same ; the point of fracture is most frequent 
in the lower third, and next in the middle. When both 
bones are broken the fracture of the fibula is usually at a 
level above that of the tibia. Of the two bones the fibula is 




FRACTURES. 271 

more frequently broken in the superior extremity than the 
tibia. Fractures of tiie bones of the leg are divided, for 
the purpose of study, into those of both bones — those of 
the tibia, those of the fibula. 

Tibia and Fibula. Causes Direct and indirect vio- 
lence, as well as muscular action, are the causes concerned 
in the production of fractures of both bones. The applica- 
tion of direct force in producing fracture is observed in the 
passage of a wheel of a wagon over the leg, the kick of a 
horse, or the crush of a mass of earth, or debris from the 
falling walls of houses in the process of demolition. Frac- 
ture, as the result of violence, applied indirectly, occurs in 
persons jumping from a height, and alighting on the feet, or 
from a railway train in lapid motion. When the fracture is 
caused by the direct application of force, the bones are severed 
at the point of contact of the force, and usually at the same 
level, the direction of the line of separation being more or 
less transverse. The application of indirect force produces 
fracture most frequently in the lower third, the separation 
taking place at different levels, and the direction of the line 
being oblique, either from behind downward and forward, 
or from without downward and inward. In fractures, the 
result of muscular action, the cause is found in the violent 
effort made by the person to regain his equilibrium at the 
time of a fall in which the body is thrown forcibly back- 
ward. The line of separation is, in this variety, frequently 
very oblique, and is usually from behind downward and 
forward. The level at which separation occurs in the two 
bones also varies. A man, thirt}^-five years of age, is now 
under my care for fracture of both bones, the result of mus- 
cular action. In walking upon the wet floor of the Morocco 
leather factory in which he was employed, he slipped, and- 



272 FRACTURES. 

in the effort to prevent falling he sustained a very oblique 
fracture of both bones, at nearly the same level. Compound 
fractures occur very frequently as the result in many 
instances of the fracturing force, and in some cases also of 
the protrusion through the soft structures of the pointed 
extremity of one or both bones. 

Symptoms The symptoms of fracture of both bones of 

the leg are well-marked, and are those which character- 
ize fractures generally, as pain, discoloration, deformity, 
preternatural mobility, and crepitus. The displacement of 
the fragments causing deformity depends largely upon the 
direction of the line of fracture and the nature of the injury. 
In transverse fractures and in those in which the point of 
separation is not on the same level the displacement is 
usually not great. In oblique fractures the tendency to 
overlapping of the fragments is very great, owing to the 
action of the gastrocnemius and soleus muscles, which draw 
up the lower fragment, producing an anterior or lateral dis- 
placement. In these cases shortening is marked. Preter- 
natural mobility is quite prominent, and crepitus can be 
both heard and felt on movement of the fragments. 

Diagnosis. — The prominent character of the symptoms 
renders the diagnosis easy. It may be difficult in cases in 
which the point of fracture is not on the same level to dis- 
tinguish the site of fracture in the fibula. As a rule, it is 
generally at a point higher than that at which the tibia 
yields. This will, to a certain extent, be a guide in seeking 
for the line of separation. Crepitus can be readily elicited 
by making extension and then rotation. If the fracture is 
very oblique, care should be exercised in making manipula- 
tions, in order to avoid giving a compound character to the 



FRACTURES. 273 

injury, by causing the protrusion through the integument, of 
the sharp points of one or both of the fragments. 

Prognosis The prognosis varies in accordance with the 

nature and extent of the fracture. In cases in which the 
line of fracture is very oblique and the displacement great, 
more or less deformity with disability will be liable to accom- 
pany the union of the fragments. Extensive overlapping 
of the fragments interferes very seriously with the repara- 
tive process, retarding it greatly, and in some instances 
causing non-union. In simple fractures the laceration of the 
tissues by the ends of the fragments may be such as provoke 
suppuration, and thus complicate the case by the development 
of a compound fracture. The laceration of the tissues with 
the involvement of the tibial arteries in compound commi- 
nuted fractures demands amputation as the means of afford- 
ing the most favorable prognosis. 

Treatment — Fractures of both bones, the result of direct 
force and in which the line of separation is transverse or 
very slightly oblique, require very simple dressings. After 
reduction, which is easily effected, they may be treated 
either in the fracture-box, or by the application of two short, 
straight splints, made of light wood, five inches in width, 
and long enough to extend from the knee to two inches 
below the sole of the foot. In preparing the latter dressing 
two or three strips of a broad bandage should be placed 
beneath the splint cloth, which should be about two feet long 
and three feet wide. Upon a soft feather pillow placed on 
this cloth the injured limb should be laid, and the splints 
rolled in the cloth so as to bring the sides of the pillow 
firmly in contact with the limb. The foot can be supported 
by a strip of broad bandage tied around its middle, and 
secured by the ends to the pillow on either side. 



274 



FRACTURES. 



Fiff. 148. 



The fracture-box (Fijr. 148) is prepared to receive the 
broken limb by placing a soft pillow in it. The limb is 

placed upon the pillow, the sides 

are drawn up and fastened with 

sufficient force to press the pillow 

equally and firmly against the leg 

so as to support it, and the foot is 

secured against the foot-piece by 

a soft handkerchief, rolled in 

cravat form, passed in figure-of-8 

turn about the ankle and foot, or simply over the foot, the 

ends being carried through the slits and tied on the outside 

(Fig. 149). 




Fig. 149. 




A great deal of comfort is afforded the patient, as well as 
success gained sometimes, in overcoming displacement by 
swinging the limb in the fracture-box. A very simple ap- 
pliance for this purpose, and one which can be quickly made, 
is seen in Fig. 150. By shortening the anterior or posterior 
cords of suspension attached to the box, the limb can be 
placed in the position of the single or double inclined plane. 



FRACTURES. 



275 



as may be desired. By this means the displacement in 
oblique fractures may be relieved in some cases without a 
resort to extension. Another method of suspension is seen 

Fi-. 150. 




in Fig. 151, which is more elaborate, and requires, for its 
manufacture, the intervention of a mechanic. In cases in 
which the line of fracture is very oblique, producing short- 
ening or marked lateral deviation, reduction should be effected 
by extension and counter-extension, and, when the displace- 
ment is lateral, replacement of the limb in the long axis ot 
the body. The displacement in these cases may be overcome 
by treatment in the straight or flexed position. When 



276 



FRACTURES. 



treated in the straight position, extension should be made by 
weights and pulley adapted to the limb placed in the fracture- 




FRACTURES. 



277 



box, as seen in Fig. 152. Counter-extension can be effected, 
if necessary, by raising the foot of the bed as in fracture of 
the femur. Lateral support is secured by raising the sides 
of the box, in which a pillow has been placed. If the frac- 

Fiff. 152. 




ture is so near the ankle-joint as to prevent the attachment 
of the stirrup of plaster to the leg in the ordinary manner, 
strips of plaster may be applied in the form of the spica of 
the instep, as practised by Prof. Agnew (Fig. 153). 



Fi^. 153. 




The apparatus of Dr. Levis, for making extension by 
weights and pulley in fractures of the femur, may be adapted 
24 



278 



FRA.CTUKES. 



to use in these cases. The upright supporting the pulley can 
be attached to the foot-board of the bed, and the weights, 
equalling twelve pounds, are so arranged that they cannot 
be easily dislodged (Fig. 154). 

¥m. 154. 




Treatment in the flexed position may be accomplished by 
suspension of the limb, by means of the appliances used in 
fracture of the femur or leg, and by the double inclined 
plane, as modified in the method of Pott. The 
latter consists of a wooden splint made to adapt 
itself to a portion of the thigh, the entire leg, 
and foot wlien the limb is in the semi-flexed 
position (Fig. 155). An opening is made to 
receive the external malleolus, and the entire 
splint should be well padded so as to avoid 
pressure. The deformity being corrected by 
extension and counter-extension, and the limb 
placed in the semi-flexed position, the splint is 
applied to the external surface, the spaces 
intervening between the limb and splint being 
filled with masses of oakum or cotton-wool. 
An internal splint, made of binder's board, 




FRACTURES. 279 

extending from the knee to tlie ankle, sliould be moulded to 
the surface after having been moistened. Jt should also 
have an opening for the internal malleolus, and should be 
well padded. Both splints should be held in place by turns 
of a roller carried from the foot to the groin. With this 
splint in position the patient can rest upon the injured limb 
if desired without displacing the fragments. 

AVlien other appliances fail to secure coaptation of the 
fragments in oblique fractures, Malgaigne's steel pin may be 
employed. This consists of a segment of a circle formed of 
steel in the ends of which are slits to receive the straps which 
secures it to the inclined plane upon which the limb rests. 
The pin passes through an opening in the centre of the arch, 
and works by a screw. In using it the pin is screwed down, 
the point of the pin penetrating the tissues to the bone. 
The strap is drawn with requisite firmness to hold the pin 
whilst it is screwed down, so as to place the fragments in 
contact. The use of this instrument is condemned by some 
surgeons, and with justice, as it is liable to cause such in- 
flammatory conditions as may give rise to erysipelas and 
suppuration, and produce, besides, the unfavorable conditions 
of a compound injury. 

In simple fractures, in which the tendency to displacement 
is slight, an immovable apparatus may be applied at the end 
of the second or third week, and the patient may be per- 
mitted to leave the bed. This appliance may consist of two 
pieces of binder's board fashioned to the shape of the leg 
and foot (Fig. 156). A roller should be applied first, and 
then the splints, after being wet in hot water, should be 
moulded to the limb, well padded and secured in position by 
a bandage. This may be removed in three weeks, and a 
simple roller applied. Stiffness of the knee and ankle-joints 



280 



FRACTUEES. 



should be relieved by friction and passive motion. A wire 
splint of Bauer (Fig. 157), or one made of tin, may be em- 
ployed in the place of that made of the binder's board, 
although this form possesses no advantage over the latter. 



Fio:. 156, 



Fi^. 157. 






A silicate of sodium or potassium, or a plaster-of-Paris 
bandage, may be used with comfort to the patient and with 
freedom from danger to the recently united bones. The 
limb should not be allowed to sustain the weight of the body 
until two mouths have elapsed from the time of the receipt 
of the injury. 

Fractures of the Tibia Fracture of the tibia occurs 

less frequently than that of both bones, and about in the 



FRACTLKES. 281 

same proportion of cases as the fibula. The site of fracture 
may be in the upper, middle, or lower third, occurring most 
frequently in the lower third or the junction of the middle 
with the lower third. The line of separation is usually 
oblique and from without, downward and inward. Separa- 
tion of the upper or lower epiphysis may occur, although 
the former is quite rare. Two years since I treated in the 
surgical ward of St. Mary's Hospital a child five years of 
age. who had sustained a compound comminuted fracture of 
the upper third of the left tibia, with separation of the 
epiphysis and dislocation at the superior tibio-fibular articu- 
lation, the result of a crush under the wheel of a street car. 
"With the exception of severe contusion, the knee-joint was 
fortunately not seriously involved. The compound character 
of the wound permitted free inspection and digital explora- 
tion of the seat of injury. Under the use of the bichloride 
of mercury dressings, combined with through-and-fh rough 
drainage, the limb was saved, with the loss of some pieces 
of necrosed bone and slight impairment of the function of 
the knee-joint. An interesting feature of this case was the 
straightening of the injured tibia by reason of the loss of 
bone and readjustment of the epiphysis and shaft. Owing 
to a rachitic condition of the child, the bones of both legs 
were curved outward. 

Fracture in the upper extremity, extending into the knee- 
joint, is a very grave injury, and complicates the fracture in 
a serious manner, especially if compound in character. 

Fracture of the internal malleolus may occur through the 
base at the point of junction with the shaft, in the middle or 
at the apex, the result of a twist of the foot, with forcible 
abduction or adduction. 

Causes — The causes of fracture of the tibia are similar to 
24* 



282 FRACTURES. 

those productive of fracture of both bones, namely, direct 
and indirect violence, as blows, kicks, and falls, and muscular 
action. The effect of muscular action is seen in old persons 
in whom a brittle condition of the bones exists. 

Symptoms The symptoms of fracture of the tibia are 

sometimes less distinct than those of the fracture of both bones. 
Owin^ to the support afforded by the fibula, the deformity is, 
as a rule, not very great, although the over-lapping of the 
fragments may exist to some extent.- Pain, discoloration, 
and swelling are usually present. Crepitus is difficult to elicit 
when the fracture is in the middle portion of the bone. At 
either extremity the parts can be manipulated in such manner 
as to develop it. Shortening to any marked extent is pre- 
vented by the resistance ojffered by the fibula. Preternatural 
mobility is more appreciable in fractures involving either 
extremity than in the shaft proper. 

Diagnosis. — The subcutaneous position of the crest of the 
tibia will enable the surgeon, if the swelling is not too great, 
to detect the seat of fracture by passing the finger over the 
surface of the bone. In the upper extremity crepitus may 
be elicited by grasping the head and shaft and making rota- 
tion. In the lower extremity and in the malleolus crepitus 
may be detected by grasping the foot and making the move- 
ments of abduction and adduction. Pressure over the mal- 
leolus with the finger may distinguish the depression, wiiich 
indicates the position of the site of fracture ; if the fibres of 
the internal lateral ligament have been torn, the displacement 
of the fragment will be more marked, and the depression can 
be more distinctly felt. 

Prognosis. — With regard to the results which follow frac- 
tures of the tibia the prognosis is generally favorable. In 
fractures of the upper or lower extremity involving the knee 



FKACTUKES. 283 

or ankle-joint anchylosis to a greater or less extent may 
supervene. Union is sometimes retarded, and non-union 
may occur. The bond of union after fracture of the malleo- 
lus is usually fibrous in character. Deformity may follow 
after union by reason of the projection of the sharp end of 
one of the fragments. This process in time is generally 
absorbed, leaving a smooth and rounded surface. If this 
does not occur, and the point is painful and the patient appre- 
hensive of injury occurring on account of the projection, it 
should be removed with the chisel or cutting pliers, or, 
what is preferable, with the large burr of the surgical 
engine. Union of the lower fragment to the fibula may 
occur, in this way, obliterating the interosseous space. 

Treatment. — The treatment of fracture of the tibia is 
similar to that employed in fracture of both bones, and may 
be effected by the use of the wooden side splints, the frac- 
ture box, splints of binder's board, felt, tin, or wire in the 
m^inner already described for those fractures. 

It is not regarded as essential in most cases to confine the 
patient in bed during the entire time required for union of 
the fragments, and it is desirable, after the subsidence of 
the swelling, which occurs at the expiration of ten days or 
two weeks, to apply an immovable dressing, which will 
afford sufficient support, and permit the patient to walk with 
the aid of crutches. The silicate bandage, with the addi- 
tion of pieces of binder's board or tin to give firmness, may 
be applied, or the plaster-of-Paris bandage in the ordinary 
form or in that known as the Bavarian splint. The Bava- 
rian splint or movable-immovable apparatus is made in the 
following manner : Two pieces of flannel of sufficient length 
and width to cover the leg and foot are cut and sewed 
together as is shown in Fig. 89. The limb is laid upon the 



284 FRACTURES. 

flannel, and each half of the inner layer is folded over the 
leg, and dorsum of the foot, joining at the median line, where 
the edges are fastened temporarily by pins (Fig. 90). Plaster, 
of proper consistence, is now applied over the inner layer, 
adapting it to the surface of the limb by a spatula or the 
fingers. When completely covered the outer layer is folded 
over the plaster, and pressed into place by the hand so as 
to conform to the shape of the limb. The pins fastening the 
edges of the inner layer are now removed, and the two 
layers of flannel, with the plaster between forming a firm 
splint, are bound together by three or four strips of bandage 
carried about the leg and foot. The double row of stitches 
fastening the two layers together forms a hinge at the back 
of the splint, so that it can be readily opened, and the parts 
inspected, or it can be removed, if necessary, and reapplied. 

Firm union of the fragments does not occur until the 
expiration of five or six weeks, up to which period the 
dressings should remain in position. 

In fractures of the upper extremity extending into the 
knee-joint careful attention should be given to the inflam- 
matory conditions which are likely to occur and complicate 
the case. The appliance, which fulfils best the indications 
present in this form of fracture, is the long fracture-box 
with compresses under the knee to afford support. If much 
displacement of the upper fragment exists, it may be neces- 
sary to place a short splint, ten to twelve inches in length, 
beneath the seat of fracture, and then place the limb in the 
long fracture-box. 

Fractures of the malleolus may be treated in the short 
fracture-box, the foot being placed in sucli position as to 
secure perfect coaptation of the fragments, and fastened 
securely to the foot piece. Lateral support should be 



FRACTURES. 285 

afforded by tlie sides of the box, protected by the pillow 
and masses of oakum or cotton-wool. 

Fractures of the Fibula. — Examination of tables 
of fractures shows that this bone suffers fracture in about 
the same propoi-tion of cases as the tibia. Fracture occurs 
most frequently in the bone of the right leg, and oftener in 
the inferior third than in either the upper or middle portion. 
Between the ages of thirty and forty is the period of life 
when fracture occurs with the greatest frequency, the largest 
number being in males. 

Causes — The majority of fractures of the fibula are caused 
by violence indirectly applied, producing a separation of the 
bony fibres at a point from one inch and a half to three 
inches above the external malleolus. The application of the 
violence is accompanied by a forcible abduction of the foot, 
by means of which the astragalus is rotated and pressed with 
great force against the external malleolus, causing, in some 
instances, rupture of the internal lateral ligament, as well as 
fracture of the fibula. This takes place in twists of the 
foot or in falls upon the inner border of the foot. According 
to Boyer, fracture at the same point may occur as the result 
of forcible adduction of the foot in falls upon the outer border. 
Direct violence may cause fracture at any point of the bone. 

Symptoms. — In fractures occurring in the upper and 
middle portions of the bone the symptoms are usually not 
very distinct. Careful examination is required to detect 
them. In the lower third, in that known as Pott's fracture, 
the symptoms are more prominent. Those which attend 
fractures generally are present as pain, swelling, discolora- 
tion, preternatural mobility, deformity, and crepitus. The 
displacement of the foot is characteristic, being markedly 
everted, and resting upon the inner border. 



286 



FRACTURES. 



Diagnosis — The protected and fixed position occupied by 
the upper two-thirds of the bone renders detection of the 
seat of fracture somewhat difficult. Pain, increased on 
movement, swelling, and discoloration are usually present, 
deformity and mobility are not marked ; crepitus may be 
elicited by deep pressure exerted upon the fragments. The 
superficial position of the lower third of the bone, associated 
w^ith its relation to the ankle-joint and foot, gives a more 
prominent character to the symptoms of fracture, and renders 
the diagnosis much easier. Great pain is experienced on 
motion. Swelling and ecchymosis are very marked ; preter- 
natural mobility is readily distinguished. The deformity 
varies in extent in accordance with the nature of the injury. 
In cases in which rupture of the internal lateral ligament 
co-exists with fracture of the fibula, the eversion of the 
foot is much greater than in fracture of the fibula alone. 
Crepitus may be elicited by grasping the foot, and making 
abduction and adduction alternately. The depression formed 
by the inversion of the ends of the fragments can be 
detected, if the swelling is not too great, by passing the 
finger over the surface of the bone ; this sulcus can be in- 
creased in depth by abducting the foot. Dislocation at the 
ankle-joint may be distinguished from fracture of the fibula 
in tlie lower third by the absence of crepitus and the perma- 
nent removal of the displacement after efforts at reduction. 
Fracture of the external malleolus may be detected by 
grasping the process, and establishing the existence of crepi- 
tus and mobility by movement of the fragments. 

Prognosis. — Union by bone takes place in fracture of the 
fibuhi at all points, with the exception, possibly, of the exter- 
nal malleolus, where the union may be sometimes fibrous in 
character. More or less disability, with chronic enlargement 



FRACTURES. 287 

about the joint, is liable to follow cases in wliicli the inter- 
nal lateral ligament has been torn, accompanied by partial 
dislocation and injury to the ankle-joint. In neglected cases, 
or in those in which the treatment has not been properly 
conducted great deformity may ensue. 

Treatment. — Fractures of the fibula in the upper and 
middle portions require in their treatment very simple 
dressings. Two pieces of binder's board, well padded, may 
be placed on either side of the leg, and secured in place by 
turns of the spiral reversed bandage, extending from the 
foot to the knee. This dressing will afford sufficient support 
to the fragments to maintain them in proper adjustment 
until union occurs. An immovable dressing, the silicate or 
plaster bandage, may be applied, and the patient be per- 
mitted to walk about with the aid of crutches. Fractures 
of the lower third of the bone, with slight displacement, 
may be treated by placing the leg in the fracture-box, care 
being taken to overcome completely the displacement by 
securing the foot, in proper position, to the foot-piece of the 
box. In cases in which rupture of the internal lateral liga- 
ment or fracture of the internal malleolus has occurred, the 
dressing must be of such character as will overcome the 
marked displacement which exists. That form which best 
accomplishes the purpose is known as Dupuytren's splint, 
and consists of an internal wooden splint, extending from 
the knee to a short distance below the foot, with a wedge- 
sliaped pad of such length as will reach from the knee to 
the internal malleolus. The splint being well padded, is 
placed, with the wedge-shaped pad, upon the inner surface of 
the leg, the large end of the pad resting just above the inter- 
nal malleolus. The upper end of the splint is fastened to 
the limb by a bandage, which is applied from the middle of 



288 FRACTURES. 

the leg to the knee. The foot is now adducted, bringing it 
in contact with the splint, and securing it in place by a 
figure-of-8 bandage, the turns of which should extend to the 
apex of the external malleolus, and not beyond (Fig. 158). 
In applying the two bandages care should be observed to 

Fig. 158. 




avoid beginning the application of the upper one too near 
the seat of fracture, and extending the lower one beyond 
the position of the external malleolus. In either event the 
objects of the dressing will be defeated in preventing the e ver- 
sion of the fragments, so as to phice them in coaptation. 
Attention should be given to the condition of the internal 
malleolus, and measures should be taken to avoid undue 
pressure upon it. After the lapse of eight to ten days, the 
reparative process having progressed far enough to main- 
tain the fragments in place, the leg may be placed in the 
fracture-box, the foot being secured to the foot-piece, and 
lateral pressure exerted by the pillow, supported by the 
sides of the box. Masses of cotton-wool or oakum may be 
placed over the external malleolus to assist, if necessary, in 
making pressure. 

Compound Fractures of the Boxes of the Leg 

Of the bones of the leg the tibia suffers more frequently 
from compound fracture than the fibula, and, as a rule, more 
frequently than any other bone of the skeleton. The 



FRACTURES. 289 

explanation of this fact is to be found in the exposed posi- 
tion occupied by the bone, and in tlie relation it occupies to 
the foot and lower extremity as a portion of the column of 
support to the body. The character of the injury in com- 
pound fractures of the bones of the leg differs very much 
in different cases. In some the injury consists of a slight 
puncture of the soft tissues, produced by the sharp end of 
one of the fragments ; in others, the rent in the overlying 
structures is very large, caused by the protrusion, to a 
marked extent, of the end, usually, of the upper fragment, 
with laceration of the soft structures, and in still other 
instances, as the result of great violence, there exists exten- 
sive protrusion of one of the fragments, with pulpification 
of the tissues and destruction of the arteries. 

Causes The cause of compound fracture of the bones of 

the \iig is usually great violence applied directly or indirectly. 
The effect of direct violence is seen in crushes by the wheel 
of a railroad car, a heavily loaded wagon, the falling of a 
wall, the kick of a horse, or a blow from a bludgeon. 
Indirect violence operates in producing compound fractures 
of these bones in falls upon the feet from a great height, or 
in a wrench of the leg, the foot being firmly fixed. Six 
years since, a lad, seventeen years of age, was admitted 
into the surgical wards of St. Mary's Hospital, who, in 
reaching out of an unguarded door, lost his balance, and 
fell to the ground, some forty feet distant, alighting upon his 
feet. He sustained a compound fracture of the left tibia, a 
simple fracture of the right fibula in the inferior third, and 
a simple fracture of the radius, also in the inferior third. 
The line of fracture of the tibia was very oblique, and the 
upper fragment, stripped of the periosteum, was protruded 
through tlie soft tissues to the extent of four inches. The 
25 



290 FRACTURES. 

protruded fragment, covered with the detached periosteum, 
was replaced, and the patient at the end of four months 
was able to leave his bed with a useful limb. 

Symjjtoms — The symptoms of compound fracture of the 
leg are sufficiently distinct, and do not require description in 
detail. 

Diagnosis — In all cases careful examination should be 
made, in order that the exact nature of the injury may be 
determined, and that proper treatment may be adopted. 
Exploration with the finger, previously washed and immersed 
in an antiseptic solution, should be made. Much information 
as to the condition of the parts will be gained by this plan 
of examination. If hemorrhage is present, careful inspec- 
tion and digital exploration will be necessary, in order to 
ascertain its extent and character. 

Prognosis — In compound fractures of the leg of not a 
severe character, the prognosis may be regarded as generally 
favorable. In those in which the soft structures have been 
much contused and lacerated, the inflammatory conditions 
which are liable to ensue will complicate the case, and render 
the prognosis doubtful. In fractures, caused by the applica- 
tion of very great violence, in which the bones are exten- 
sively comminuted, the soft tissues ground into a pulpy mass, 
and the bloodvessels lacerated, the prognosis is most unfavor- 
able, the removal of the limb being demanded as necessary to 
save the life of the patient. More or less deformity is liable 
to follow union in all compound fractures, and anchylosis 
when the knee or ankle-joint is involved. 

Treatment — The question of making an attempt to save 
the limb in the treatment or remove it, is one which the 
surgeon is called upon to decide in cases of compound frac- 
ture of the leg. Good judgment is, therefore, to be exer- 



FRACTURES. 291 

cised, with careful consideration of all the conditions which 
present themselves in each individual case. The general 
condition of the patient's health, his habits of life, as well 
as the nature of the injury, are to be taken into careful con- 
sideration. In cases in which the external wound is small, 
and but slight laceration of the tissues has taken place, the 
limb should be placed on the pillow in the fracture-box, and 
an effort should be made to convert the fracture into a 
simple one by closing the wound. This may be accomplished, 
after cleansing it thoroughly and bathing with a dilute solu- 
tion of carbolic acid, by introducing silver-sutures or drawing 
the edges together with adhesive plaster. An effort should 
be made to seal the wound hermetically, so that air cannot 
gain admission, by the application of collodion and gauze or 
other agents. Antiseptic dressings should be applied over 
the wound, and the limb kept at rest, in the hope that tlie 
external wound will promptly heal. 

When the injury is of a more serious character, with pro- 
trusion of the fragment, and extensive laceration of the soft 
structures a different plan of treatment should be pursued. 
The protruding fragment shoukl be replaced by manipulation 
— flexion and extension, with counter-extension of the limb, 
being employed in turn, if necessary, to effect this. Sepa- 
ration of the edges of the wound with retractors, or enlarge- 
ment of tlie opening by incision may be practised if replace- 
ment is found difficult. It may be necessary, in some cases, 
to remove w^ith the cutting-pliers or saw, a portion of the 
fragments, in order to reduce the fracture. All other means 
should be exhausted before resorting to this operation, as it 
leaves the fragments in sucli condition as to interfere with 
the reparative process. The fragment being replaced, the 
edges of the wound may be drawn together, and secured by 



292 FRACTURES. 

sutures if the laceration of the tissues is not too great. It 
is desirable, in these cases, to introduce drainage-tubes, and 
bring the edges of the wound together about them. By this 
means the wound-fluids will be removed, and the tendency 
to suppuration averted. Antiseptic dressings should be 
applied to the wound, and the limb placed in the fracture- 
box or in an immovable dressing, with a fenestrum over the 
wound, as shown in Fig. 91. A favorite plan of dressing 
employed in this city in these cases, consists in placing the 
limb in the fracture-box, and surrounding it with coarse bran, 
as originally practised by Dr. John Rhea Barton. The bran 
affords equable pressure, and absorbs the discharges from 
the wound as they appear. Removal of the soiled bran, and 
the addition of that which is clean is readily effected. In 
compound comminuted fractures the loose and detached 
pieces of bone should be removed, and drainage-tubes 
should be introduced, so as to drain the wound thoroughly. 
If suppuration occurs, counter-openings may be made, if 
found necessary to secure complete drainage. Antiseptic 
dressings should be employed in all cases of compound frac- 
tures of the leg, and immobilization of the fragments should 
be secured by appropriate appliances. With the aid of this 
form of dressing limbs formerly condemned for removal are 
saved and made useful. 

Hemorrhage, venous or arterial in character, frequently 
occurs in connection with compound fractures of the leg, 
and increases their gravity. Venous hemorrhage may be 
controlled by pressure exerted uniformly upon the parts, or 
by the application of cold compresses. Care should be 
taken that the blood is not confined in the wound, where it 
may collect and lead to suppuration. If arterial hemor- 
rhage does not yield to pressure or other simple measures, 



FllACTUKES. 293 

the wound should be enhirged, if necessary, the bleeding 
vessel sought, and a ligature applied. Hemorrhage from 
the nutrient artery is sometimes severe. It may be con- 
trolled by plugging the canal temporarily with a piece of 
soft wood, or permanently with a piece of animal ligature. 

Foot Simple fractures of the bones of the foot are rare. 

The astragalus and os calcis are the bones of the tarsus 
which most frequently sustain fracture. Of the metatarsus 
and phalanges those of the great toe are most frequently 
broken. Compound fractures occur very frequently. 

Causes Direct and indirect violence and muscular action 

are assigned as causes. The os calcis, with the metatarsal 
bones and phalanges, sustain fracture as the result of direct 
force, as in the crush of the foot under the wheel of a car. 
Instances are recorded in which forcible contraction of the 
calf muscles has produced fracture of os calcis. The astra- 
galus is generally broken by force transmitted through the 
OS calcis, as in falls upon the feet. The direction of the 
line of fracture varies in the different bones, being transverse, 
vertical, and horizontal. 

Astragalus. Symptoms. — AVedged in as the astragalus 
is between the malleoli, it is impossible, as a rule, in simple 
fractures, to observe any symptoms characteristic of fracture. 
Pain and swelling, with loss of function may be present. 
Crepitus may be detected by manipulation, flexion and 
extension, or abduction and adduction of the foot. Defor- 
mity is not usually present. 

Diagnosis — The absence of marked symptoms in simple 
fractures renders the diagnosis very difficult. If displace- 
ment exist the seat of fracture may be detected. Crepitus, 
if obtained, will assist in making the diagnosis. In com- 

25* 



294 FRACTURES. 

pound fractures the parts can be inspected and explored with 
the finger. 

Prognosis — Favorable in simple fractures. In compound 
and comminuted fractures the involvement of the ankle- 
joint, and, in some instances, of the adjacent tarsal joints 
renders the prognosis very unfavorable. If amputation or 
excision is not demanded, anchylosis, more or less complete, 
will follow repair. 

Treatment. — In uncomplicated cases the treatment con- 
sists in placing the limb for a few days in the fracture-box, 
and applying the applications locally to allay the swelling. 
When this has subsided an immovable dressing of plaster or 
silicate of sodium should be applied, and the patient should 
be permitted to walk about with the aid of crutches. When 
displacement of one of the fragments exists, an effort should be 
made, by manipulation, to reduce it, which is frequently an 
unsuccessful operation. If reduction cannot be effected it is 
thought desirable by some authorities to permit the fragment 
to remain in its displaced position, with the accompanying 
deformity. Other authorities are equally strong in their 
opinion that excision, not only of the fragment, but of the 
whole bone, should be performed, in order to remove deform- 
ity and disability. The excision of the entire bone is recom- 
mended, on account of the danger of the occurrence of 
necrosis in the remaining fragment, and of the consequent 
involvement of the bones of the ankle-joint. 

In compound and comminuted fractures the question of 
amputation or excision presents itself for serious considera- 
tion. The action of the surgeon should be based upon a 
careful consideration of all the conditions present. 

Os Calcis. Symptoms The symptoms of fracture of 

the OS calcis vary in accordance with the position of the 



FKACTUKES. 295 

fracture. If it is sub-astragaloid in character, the trans- 
verse diameter of the bone is increased, while the vertical is 
diminished, giving rise to a decided flattening of the heel. 
Pain, increased on movement, is present, whilst the swelling 
is circumscribed in character, being confined, according to 
Malgaigne, as quoted by Prof. Agnew, " to the parts below 
the front of the ankle and the malleoli, and to the sole of 
the foot." In this form of fracture the bone is generally 
comminuted, and sometimes impacted. Crepitus is difficult 
to elicit by reason of this impaction. In fracture of the 
post-astragaloid or heel portion of the bone, the symptoms, 
owing to its connection with the calf muscles and its promi- 
nent projection, are more distinct. Pain and swelling are 
present, with mobility and deformity. The deformity is 
produced by the action of the gastrocnemius and soleus 
muscles, w^hich draw backward and upward the posterior 
fragment. This displacement upward is especially marked 
if the line of separation is near to the insertion of the tendo 
Achillis. Crepitus can be detected by flexing the knee and 
ankle-joints, and, after grasping the fragment, making rota- 
tion. 

Diagnosis — The diagnosis is made by a careful examina- 
tion and study of the symptoms as they present themselves 
in the two forms of fracture. In the subastragaloid variety 
they are somewhat difficult of recognition, whilst in fractures 
of the heel portion they are sufficiently distinct to render 
tiie diagnosis easy. 

Prognosis — Disability to a greater or less extent is liable 
to follow fracture in the sub-astragaloid portion of the bone. 
In the post-astragaloid variety of fracture union occurs, 
under ordinary conditions, in the usual period — five or six 
weeks — and usually without great disability. 



29G 



FKACTURKl 



Fiff. 159. 



Treatment — In the post-astragaloid variety of fracture 
the indications for treatment are to adopt such an appliance 
as will place the fragment in contact with the bone, and 
maintain it in this position. This can be accomplished by 
flexing the leg upon the thigh, and the foot upon the leg. 
The fragment should then be drawn down into place, and 
secured by the application of a strip of adhesive plaster, or 
the turns of a figure-of-8 bandage of the instep. 
Tiie limb in the flexed position should be 
secured to a double angular splint (Fig. 155) 
by turns of a roller carried from the foot to 
above the knee. When tlie swelling has dis- 
appeared an immovable dressing may be ap- 
plied in place of the splint. Other forms of 
dressings have been employed. Fig. 159 
shows that of Monro, which consists of a 
wooden splint, placed on the front of the leg 
and over the dorsum of the foot. 

In the sub-astragaloid variety of fracture, an 
immovable dressing may be applied when the 
inflammatory conditions have subsided. 

Metatarsus. Symptoms The symptoms 

of fracture of the metatarsal bones are well 
marked. Occurring as the result of direct 
violence the displacement is not great. Mobil- 
ity and crepitus are present, and easily recog- 
nized. 
Diagnosis. — As in the metacarpus, the parts are so readily 
accessible that the diagnosis is not attended with any diffi- 
culty. Crepitus can be easily elicited by grasping the parts 
and moving the fragments upon each other. 

Prognosis. — The prognosis in fractures of the metatarsal 



FRACTURES. 297 

bones is favorable, union taking place without difficulty. In 
compound and comminuted fractures deformity may follow 
as .the result of the injury. 

Treatment Tn simple fractures the fragments should be 

reduced, and the limb placed in a fracture-box, with the 
foot secured to the foot-piece by a handkerchief in cravat 
form, or a splint of binder's board may be moulded to the 
posterior surface of the leg and plantar surface of the foot, 
and, after being well padded, may be secured in place by 
turns of a roller. An immovable dressing applied to the 
foot and leg will aflbrd an excellent support in fractures of 
this kind. Compound fractures should be treated with anti- 
septic dressings and appropriate splints to secure rest. 

Phalanges. Symptoms Simple fractures of the pha- 
langes are attended by the usual symptoms of fracture, as 
pain, swelling, mobility, and crepitus. Deformity is not usu- 
ally well marked, except, perhaps, in cases of fracture of the 
phalanges of the great toe. Compound fractures, the result 
of a crush by the falling of a piece of timber or metal upon 
the toes, present prominent symptoms. The parts can be 
examined easily, and the nature of the fracture determined. 

Diagnosis The diagnosis may be difficult in simple 

fractures of the smaller toes. In the great toe, where frac- 
ture occurs most frequently, the symptoms are so distinct as 
to render the diagnosis easy. 

Prognosis. — Union may occur with some deformity, 
otherwise the prognosis is favorable. 

Treatment. — In simple fractures, a wooden splint or one 
made of binder's board, after being well padded, may be 
secured to the plantar surface of the foot by turns of a 
roller. Strips of adhesive plaster may be applied about the 
toe to maintain approximation of the fragments, if found 



298 FRACTURES. 

necessary. If anchylosis is threatened, the toe should be 
placed in the straight position, so as to avoid pressure of the 
shoe on a permanently flexed joint. An immovable dress- 
ing extending to the leg may be substituted for those 
described. 



PART IV. 

DISLOCATIOXS. 



Definition. — A dislocation or luxation is a separation 
of the surfaces of the bones entering into the formation of 
an articulation or joint. 

Varieties 1. Traumatic; 2. Pathological; 3. Con- 
genital. 

1. Traumatic Dislocations are the results of injuries, 
and are divided into Complete — Incomplete — Simple — Com- 
plicated — Single — Double — Unilateral — Bilateral — Primi- 
tive — Secondary — Recent and Old. 

Complete Dislocations are those in which an entire sepa- 
ration of the articular surfaces occurs, accompanied by an 
elongation or rupture of the ligaments of the joint. 

Incomplete or Partial Dislocations are those in which 
the separation of the articular surfaces is not complete, a 
portion of the surfaces remaining in contact, with, as a rule, 
elongation and not rupture of the ligaments. 

Simple Dislocations — Dislocations are designated as sim- 
ple when they are unaccompanied by any other condition 
than sepai-ation of the articular surfaces, with or without 
rupture of the ligaments. 

Complicated Dislocations Those which are attended by 

lesions in addition to the separation of the articular surfaces, 



300 DISLOCATIONS. 

as fracture of one or all of the bones entering into forma- 
tion of the joint, the production of a wound of the soft tis- 
sues communicating with the articulation, wounds of im- 
portant bloodvessels or nerves, or extensive contusion and 
laceration of the soft structures. 

Single Dislocations Dislocations involving one joint 

only are designated single. 

Double Dislocations are those in which the luxation oc- 
curs in corresponding articulations on both sides of the body. 

Unilateral Dislocations These take place in one articu- 
lation of a single bone. 

Bilateral Dislocations The dislocation is bilateral when 

a separation of the articular surfaces occurs in both articula- 
tions of the bone. 

Primitive Dislocations The term primitive is used in 

connection with dislocations to designate the original posi- 
tion in which the bone is placed. 

Consecutive Dislocations A consecutive or secondary 

dislocation is one in which the bone, for some cause, assumes 
a new position. 

Recent Dislocations — The term recent is applied to dis- 
locations occurring within a short period of time — as a few 
days or weeks — before any changes have taken place in the 
parts. 

Old Dislocations Dislocations are designated as old 

when some time has elapsed since the receipt of the injury 
— from a few months to a year or more — after the occur- 
rence of such changes in the articulation as to greatly im- 
pair or destroy it. 

2. Pathological Dislocations are those in which the 
separation of the articular surfaces has taken place as the 
result of disease in one or both. This condition is most fre- 



DISLOCATIONS. 301 

qiiently observed in tlie hip- and knee-joints consequent 
upon chronic inHammation. As a result of the inflamma- 
tory action the structures of the joint are partially or com- 
pletely destroyed, so that they cannot resist the muscular 
contraction exerted, and therefore the distal or movable bone 
is drawn away from the articular surface or cavity, in con- 
tact with which it is normally placed. The separation is 
progressive, and extends sometimes to the distance of three 
or more inches (Fig. IGO). 

Fig. 160. 




3. Congenital Dislocations are those which occur 
during the life of the fcetus in utero, and may be caused by 
external violence, disease of the articulations, or arrest of 
development. They occur most frequently in the shoulder-, 
w rist-, or hip-joints, and in females oftener than in males. 
Accompanying the dislocation, and in some instances caused 
by it, are marked alterations in the articulations and in the 
structures about them. 

Causes of Dislocation. 

Predisposing and Exciting. — Predisposing causes em- 
brace age, sex, occupation, articular disease, and peculiar 
formation of the articulation. 
26 



302 DISLOCATIONS. 

Age.— Age exercises an influence in the production of dis- 
locations in the development and decline of the muscular 
power. Dislocations occur most frequently in middle life — 
rarely, as a rule, in very young or old age. The develop- 
ment of the muscular structures in middle life contributes 
to the occurrence of those luxations caused by muscular 
action. 

Sex Dislocations occur more frequently in males than 

in femaks, the explanation of which is to be found in their 
different modes of life. 

Occupatio7i. — This cause conduces to the occurrence of 
dislocations in the exposure to injury incident to the occu- 
pation of the individual. 

Articulm^ Disease The chancres occurrinoj in an articu- 

lation due to morbid conditions predispose to dislocations. 

Peculiar Formation of the Articulation ^The construc- 
tion of the articulation influences largely the occurrence of 
dislocation. Those in which motion is extensive, as the 
ball-and-socket joints, are much more liable to suffer from 
luxation than the hinge-joints. 

The EXCITING causes of dislocations are external violence 
and muscular action. 

External violence mny exert Its influence in two ways — 
directly and indirectly. The effect of the former is observed 
in the application of force directly over the articulation, and 
of the latter in the transmission of the force from a distal 
part to the joint, upon which it is expended. 

Muscular Action This cause is effective in violent and 

j^^smodic action of the muscles, the articular surfaces being 
at the time in a position favorable to separation under its 
influ-ence. 

In discussino; the causes of dislocation it is desirable to 



DISLOCATIONS. 803- 

» 

consider, as an important factor in tlieir production, the rela- 
tive position of tiie articular surfaces at the time of the ap- 
plication of the force. A partial separation of the surfaces, 
with a relaxed condition of the surrounding structures, and 
the position of the distal bone at an angle to the articular 
surface above, favor very materially the production of dis- 
location. 

Patholoyical Characters — An examination of an articu- 
lation recently the subject of a complete dislocation, will 
reveal a laceration of the ligaments more or less extensive 
with separation of the articular surfaces. The condition ob- 
served in the ligaments varies — in some instances there is 
an elongation, with a slight rent sufficient only to permit the 
escape of the bone — in others, the laceration is extensive, 
the ligaments being torn from their bony attachments. In 
dislocations, the result of very violent force, the muscles and 
tendons are contused, and in some cases lacerated. In luxa- 
tions caused by muscular action the laceration of the ligaments 
is much less extensive, the displacement being accomplished 
rather by elongation with slight rupture. Capsular liga- 
ments, it is observed, suffer more extensive laceration than 
those formed of bands. 

As a rule, the large bloodvessels in relation with the ar- 
ticulation escape injury, the bleeding which follows luxation 
being caused by the rupture of the small articular branches. 
Laceration of the large nerves is an extremely rare accident. 
Frequently they are subjected to pressure producing numb- 
ness, and in some instances neuralgic pains and paralysis. 

The separation of the articular surfaces varies in accord- 
ance with the amount of force applied in producing the dis- 
location, the extent of rupture of the ligaments and the 
manner in which the muscular action is expended upon the; 



304 DISLOCATIONS. 

displaced bone. The articular surfaces may be partially in 
contact or entirely separated, the luxated bone resting upon 
an adjacent muscle, tendon, or surface of bone, or upon all 
of these conjointly. Blood partially fluid or coagulated oc- 
cupies the cavity of the joint. If the dislocation is allowed 
to remain unreduced for several days, inflammatory exuda- 
tions will be deposited in the cavity of the articulation and 
in the surrounding tissues, uniting them in a mass. If a still 
longer period is permitted to elapse, marked and important 
changes take place in all of the structures entering into the 
formation of»the joint. The ligaments undergo atrophy and 
become lost in the surrounding tissues. The articular sur- 
faces of the bones lose their cartilajjinous coverins^s and be- 
come smooth and hard. An atrophic change takes place in 
these, and they become flattened. 

In the enarthrodial or ball-and-socket variety of articu- 
lation, the articular cavity may disappear either by absorp- 
tion or by the development of fibrous or bony tissue from the 
surface. The head of the displaced bone, if resting upon a 
muscle, is soon surrounded by a deposit of plastic matter 
which is converted into an adventitious capsule of a dense 
fibrous character, resembling in some respects the original 
capsule. Similar action takes place if it is lodged upon the 
surface of a bone, with the addition of the foraiation of an 
osseous rim about the cavity, produced by absorption of the 
bone. The surface of the cavity as well as of the articu- 
lating bone becomes eburnated and the movements in the 
improvised articulation are accompanied by a grating noise. 
Changes occur also in the muscles and tendons surrounding 
the articulation. By reason of the disuse, consequent upon 
tlie condition of the articulation, they become contracted and 
rigid, and may finally undergo fatty degeneration. The large 



DISLOCATIONS. 305 

bloodvessels and nerve trunks may be embraced in tlie gene- 
ral mass of inflammatory deposit and become attached to the 
newly-formed capsule or by bands of adhesions to the dis- 
placed bone. As a result of this gluing together of the 
structures these vessels and nerves are liable to sustain rup- 
ture under efforts made at reduction, exposing the patient to 
the dangers of fatal hemorrhage or the condition consequent 
upon laceration of a large nerve. 

The new joint formed by the process above described, 
whilst in many respects very imperfect, may permit the pa- 
tient to enjoy very good motion which may -be improved 
under use. On the other hand, its functions may deterio- 
rate and the joint finally become useless. Tlie entire limb 
participates in the changes occurring as the result of the loss 
of function in the articulation as manifested by atrophy of 
the muscular structures and diminished circulation. 

In ginglymoid articulations the changes following unre- 
duced dislocations of recent or long-standing are less exten- 
sive than those observed in the enarthrodial variety. At 
the same time, they are of such character as to render re- 
duction impossible in a much shorter period than in the ball- 
and-socket joints. 

Symptoms of Dislocation. 

The symptoms of dislocation are pain, loss of function, 
deformity, and immobility. 

Pain — This symptom varies greatly in extent and char- 
acter. In some instances it is slight and experienced only 
on attempts at making movements, and is due to the contu- 
sion of the soft tissues and laceration of the ligaments. In 
other cases it is very severe, produced by pressure by the 

2G* 



306 DISLQCATIOXS. 

displaced bone upon a large nerve. Instead of pain, patients 
will sometimes complain of numbness extending the entire 
length of the limb. 

Loss of Function As a rule, loss of function is very 

marked in dislocations, the patient being unable to make, if 
any, but the slightest movement of the limb. 

Deformity Deformity manifests itself in different ways, 

as to change in the contour of the joint, the length of the 
limb and its axis. The configuration of the joint is always 
more or less affected ; this is observed in some articulations 
in the absence of the natural rotundity of the parts, a flat- 
tened appearance being presented in its place, with the 
prominent projection of the bony processes. With few ex- 
ceptions the limb is shortened under the infiut.nce of the 
muscular action, the extent of shortening varying in different 
dislocations. In some forms of dislocation great distortion 
attends the condition, and the axis of the limb is notably 
affected, being markedly abducted, inverted, or everted, as 
influenced by the position of the displaced surfaces and the 
muscular action. 

Immobility Immobility is one of the most prominent 

and constant symptoms of dislocation. In complete luxations 
the interference with tlie normal movements of the joint is 
very marked and most readily recognized. In dislocations 
affecting certain articulations the immobility is almost abso- 
lute. The patient is unable to exercise any control over the 
movements of the limb, and the efforts of the surgeon are 
unavailing in effecting more than a very limited motion. 
The rigidity of the limb is due to various causes which may 
act separately or conjointly ; these are muscular action, the 
obstruction offered by prominent bony processes, and the 
constriction produced by the ruptured ligamentous structures. 



DISLOCATIONS. 307 

In addition to the symptoms above enumerated, there may- 
be swelling, discoloration, and crepitus, or friction sound. 

Swelling, if it occurs immediately or very soon after the 
receipt of the injury, is due to hemorrhagic eifusion and 
is soon followed by marked discoloration. Appearing at a 
later period it may be regarded as the result of inflammation, 
and increases with greater or less rapidity in accordance 
with the intensity of the action. Effusions of blood may 
precede and accompany the deposition of inflammatory pro- 
ducts, and their combined efi'ect will increase the swelling 
and discoloration, rendering tlie part hard,* glossy, very 
painful and intolerant of manipulation. 

Manipulation of the injured joint in some instances gives 
rise to a sound which has been designated by some authori- 
ties as crepitus. The sound produced is quite different from 
that elicited in fractures as the result of moving the frag- 
ments of broken bone upon each other with their surfaces in 
contact. Friction expresses better the sound heard, and is 
properly applied to indicate the cause which is ascribed to 
the presence of an exudation of plastic matter in the joint. 
It is a very uncertain symptom and cannot be relied upon in 
making a diagnosis. 

Diagnosis — There is no class of injuries in which a 
thorougk knowledge of anatomy is more requisite, in order 
to comprehend the conditions present, than in dislocations. 
The surgeon must have a knowledge of the normal anatomy 
of the articulation before he can appreciate the departure 
from this which exists in luxation. He must understand 
the relations of the different surface markings to the articu- 
lation and to each other to enable him to recognize any 
change which may occur in them. In arriving at a correct 
interpretation of the symptoms present, careful examination 



30S DISLOCATIOXS. 

is necessary. The injured joint should be inspected and 
compared ^vith that of the opposite side as to contour, mo- 
bility, and function. Measurements should be made to de- 
termine any differences which may exist as to length and 
width of the limb and affected part. It is desirable, in 
almost all cases, especially in luxations involving the larger 
joints, to make the manipulations necessary under the influ- 
ence of an anaesthetic agent. The removal of muscular 
spasm and the complete relaxation of the muscular system 
obtained by anaesthesia is essential to a satisfactory exami- 
nation of the part. Moreover, reduction may be effected 
whilst the patient is in this condition if dislocation is found 
to exist. 

The differential diagnosis between dislocations, fractures 
near to or involving a joint, and sprains, requires a careful 
study of the symptoms of each and their comparison. Pain, 
loss of function, and deformity, are common to all, although 
differing in character in each ; the characteristic symptoms- 
of fractures are preternatural mohility and crepitus, while 
those of dislocation are preternatural immobility and absence 
of crepitus. In sprains the normal movements are limited 
only, not abnormally increased or entirely prevented, and 
crepitus is absent. In both dislocations and sprains friction 
sounds may be detected after the supervention of inflamma- 
tion. 

It is desirable to make the examination in cases of dislo- 
cation as soon after the receipt of the injury as possible, be- 
fore the occurrence of swelling and other conditions liable 
to render the diagnosis difficult. 

Prognosis — The prognosis, as far as it relates to reduc- 
tion is, in recent dislocations, favorable. In old dislocations 
it is verv unfavorable as will be seen further on. More or 



DISLOCATIONS 309 

less (Usability with disordered sensibility remains after dis- 
location in almost all cases. Tlie danger to life attending 
dislocation is, as a rule, slight, and differs in accordance with 
the character of the injury and of the joint involved. In 
recent cases, dislocation of a ball-and-socket joint is more 
diflicult to overcome than of a hinge -joint. Reduction, how- 
ever, can be effected in an enarthrodial joint with greater, 
ease after a lapse of time than in the ginglymoid variety. 

In females, old persons, and children, reduction is more 
readily accomplished than in adult males, owing to their 
slight or impaired muscular development. 

Treatment — The treatment of dislocations consists in the 
restoration to the normal position of the separated articular 
surfaces, their retention in place by suitable dressings* until 
the injured structures are repaired, the application of sucli 
remedies as will allay inflammatory action which may occur, 
and the employment of such measures as will restore the 
normal functions of the joint. 

Reduction of the dislocation may be effected by means of 
manipulation or the application of force. In effecting re- 
duction by manipulation the patient should, as a rule, oc- 
cupy the recumbent position, and should be placed under the 
influence of an anaesthetic. The administration of an anres- 
thetic may not be necessary if the patient is seen immedi- 
ately after the receipt of the injury, when the absence of 
strong muscular action and the condition of shock present, 
may facilitate the reduction of the dislocation. The patient 
being completely under the influence of the anaesthetic, with 
the muscles in a state of relaxation, the surgeon should 
make a careful examination so as to ascertain the position 
of the displaced bone, the site, if possible, of the rupture 
in the ligamentous structures through which it has escaped, 



310 DISLOCATIONS. 

and the structure offering obstruction to its return, whether 
a tendon of a muscle or a bony process in relation with the 
joint, or the tightly drawn edges of the rent in the ligament. 
He should also endeavor to determine the course taken by 
the bone at the time of the displacement, in order to direct 
his manipulative efforts, so as to accomplish its return with 
the least resistance. 

The manipulations should consist of extension, counter- 
extension, and pressure, with, if required, the movements 
belonging to the articulation, as abduction, adduction, flex- 
ion, and rotation. The movements necessary to be made 
having been determined upon they should be executed with 
deliberation and in a systematic manner. If, in their exe- 
cution, reduction is not effected, an examination should be 
made to ascertain the cause of obstruction, and, if possible, 
tliis should be overcome by manipulations performed in other 
directions. In this manner a bone maybe relieved from a fixed 
position and the luxation, which had before resisted all efforts, 
reduced. Aimless movements should not be made, as they 
have a tendency to increase the difficulties in effecting re- 
duction by further displacement of the bone and to cause 
laceration of the tissues. 

Reduction by force is accomplished through the instru- 
mentality of certain appliances by means of which it is most 
effectually applied. In this method counter-extension is 
effected by the efforts of an assistant who grasps the part, 
or by strong counter-extending bands. 

Extension is made by the surgeon in the direction of the 
long axis of the limb by grasping it with the hands or through 
the median of the clove hitch (Fig. 161), or Indian basket, 
or other contrivance which enables him to accomplish trac- 
tion with better advantage. 



DISLOCATIONS. 
Ficr. 161. 



311 




If greater mechanical power is desired it can be obtained 
by the use of tlie compound pulleys (Fig. 162), the rope 
windlass, the dislocation tourniquet, or Jarvis's adjuster. 

In the application of the compound pulleys the patient 
should be in the recumbent position, and a soft, Avet napkin 
or towel long enough to go around the limb twice should be 
applied. Over this the noose or clove hitch, made from 
some strong and soft material folded in the form of the cra- 
vat, should be placed and one hook of the pulleys fastened 
to it. The other hook should be secured to a staple screwed 
into the door jamb or other convenient place. The ccrd 
should then be gradually tiglitened, great care being taken 
to apply the traction so as to avoid the infliction of injury 
to the soft structures, or to produce fracture of the bone. 



312 



LUSLOCATIOXS. 

Fi-. 162. 




With the appliances above mentioned great force can be 
exerted, and they should, therefore, be employed with the 
utmost caution. 

That they have done injury, even in the hands of skilful 
surgeons, is unquestioned, and it is desirable that their use 
should be entirely dispensed with. The success which has 
attended the employment of manipulation in effecting re- 
duction of recent and also of old dislocations justifies the 
belief that their application is not necessary in any form. 

Continuous extension, exerted by rubber bands or by 
Aveights, has been successful, in a number of instances, in re- 
ducing luxations which have resisted other methods. 

Subcutaneous division of muscles, tendons, ligaments, and 
fibrous bands, which have offered unyielding obstruction to 
the return of the dislocated bone, has been practised by Dif- 
fenbach and others. The operation is attended with danger 
to vessels and nerves in relation with the articulation, and is 
liable to give rise to inflammatory conditions. I have seen a 
fatal result follow its employment by a most skilful surgeon. 



DISLOCATIONS. 313 

The evidence that reduction of a dislocation has been 
effected is found in a decrease of the pain, the removal of 
the accompanying deformity, with more or less complete 
restoration of the functions of the limb. In some instances, 
the return of the bone is accompanied by a distinct snap, 
which is heard by those present. In other cases, owing to 
the relaxed condition of the parts under the influence of the 
anaesthetic, the bone returns to its place without this sound. 

The treatment after reduction consists in combating in- 
flammation, if present, by appropriate remedies, and in the 
application of dressings to retain the bone in place ; these 
should remain in position for different periods of time, ac- 
cording to the character of the dislocation. 

At the expiration of ten days to two weeks passive mo- 
tion, with friction, should be instituted to prevent anchy- 
losis and restore the functions of the joint. 

Complicated Dislocations As stated above, various con- 
ditions complicate dislocation, and among them fracture of 
the displaced bone and the compound character of the dis- 
location are of the greatest importance, and require special 
directions as to the treatment to be adopted. In cases where 
it is possible, the fracture should be first reduced and the 
fragments retained in apposition by appropriate dressings. 
A primary roller should be applied to the limb, and the frac- 
ture supported by tlie application of a number of well-padded 
narrow splints, which should be secured in place by a second 
roller. Under the influence of an anaesthetic, reduction of 
the dislocation should now be effected by careful manipula- 
tion or force, the limb being grasped over the splints, and if 
possible, above the seat of fracture. Dressings should be 
applied after reduction, to prevent the recurrence of dis- 
placement. If the seat of fracture is so near the joint as to 
27 



314 DISLOCATIONS. 

prevent proper immobilization of the fragments prior to ef- 
forts at reduction of the dislocation, these should be made 
first, the surgeoii endeavoring by pressure upon the displaced 
bone to reduce it. Dressings should then be applied, which 
will have the combined effect of retaining the displaced bone 
and fragments of the fracture in place. 

Compound dislocations occur as the result of external vio- 
lence applied over the joints, or the forcible extrusion of the 
dislocated bone through the structures. In the former, the 
wound is made from without inv\^ard, and in the latter, from 
within outward. The causes of the injury are blows, pro- 
ducing usually the dislocation from without inward, and 
falls, in which the application of the indirect force protrudes 
the bone through the tissues. The articulations most liable 
to suffer from this form of injury are the elbow, knee, and 
ankle, all of the ginglymoid or hinge variety. 

The symptoms are so plain as not to require special de- 
scription. 

The diagnosis is not difficult, owing to the ease with which 
the parts can be examined by inspection, and, if necessary, 
explored with the finger. 

Tiie treatment of these injuries demands the most careful 
consideration. The great responsibility of decision in these 
cases with regard to the question of removal of the limb or 
of an attempt to save it, rests upon the surgeon, and he must 
act promptly. The presence of tlie following conditions are 
usually regarded as sufficient to justify the surgeon to resort 
to immediate amputation : Extensive contusion and lacera- 
tion of the soft tissues with free exposure of a large joint, 
great comminution of the luxated bone, rupture of large 
arteries or nerves, and finally, the advanced age of the pa- 
tient, the existence of ill-health or dissipated habits. Am- 



DISLOCATIONS. 315 

putation as a secondary operation may be required later wlien 
after an attempt to save the limb has been made, gangrene 
or exhaustive suppuration has supervened. Still further, 
amputation may be performed with propriety, where great 
deformity, impairing markedly the function of a limb, fol- 
lows conservative treatment. 

Primary excision may be performed with advantage in- 
stead of amputation, where some of the conditions above 
stated exist, especially in those involving the shoulder- 
joint. It may be performed secondarily in cases in which 
necrosis has attacked the bones of the joints. 

When, after careful consideration of all the conditions 
present, it is decided to make an effort to save the limb, 
the following plan of treatment should be pursued. Tiie 
parts should be thoroughly cleansed with a one to forty solu- 
tion of carbolic acid, or one to two thousand solution of corro- 
sive sublimate, using for tiiis purpose the fountain syringe. 
If comminution of the bone exists, all loose fragments 
should be carefully removed with the forceps or fingers of the 
surgeon. When the displaced bone protrudes through the 
wound it should be returned by manipulation. Extension 
with pressure upon the extremity may be able to effect 
this. If it is firmly grasped by the edges of the rent in the 
tissues they should be separated by means of retractors, and 
if this is not sufficient the opening may be cautiously en- 
larged by incision with the probe-pointed bistoury. It may 
be necessary in some cases to divide certain muscles or ten- 
dons, the tension of which cannot be overcome by manipu- 
lation, and also to remove with the saw or cutting pliers the 
end of the displaced bone which interferes with reduction ; 
this last operation should be left, however, as a dernier res- 
sort, the objections obtaining against this procedure being the 



316 DISLOCATIONS. 

same as in compound fracture. With regard to the removal 
of the uninjured articular surfaces, Prof. Agnew states that 
in his experience " it is the safest course to cut away the 
displaced ends of the articulating bones." The late Prof. 
Gross was, on the contrary, very emphatic in his declaration 
" that retrenchment should be performed in cases only where 
the end of the bone is sharp, angular, or denuded of peri- 
osteum, and such a step should be taken only after the most 
thorough conviction of its imperative necessity. He could 
hardly conceive of a case where it would be necessary to re- 
move the end of a dislocated bone, simply because it pro- 
trudes at a wound." 

The displaced bone having been reduced and the ligaments 
carefully adjusted so as not to rest betw^een the articulating 
surfaces, drainage-tubes should be introduced to secure com- 
plete removal of the wound fluids and the edges of the wound 
accurately approximated by silver sutures or adhesive plas- 
ter. The corrosive sublimate dressings should be now applied 
and retained in place by bandages. If the injury occurs in the 
upper extremity, immobilization should be effected by appro- 
priate splints, such as those described in connectioii with 
compound fractures involving the articulations. In com- 
pound dislocations involving the joints of the lower extrem- 
ity, the patient should occupy the bed, and antiseptic dress- 
ings should be applied with the fracture-box, bracketed 
splint, or plaster bandage, with fenestrum over the wound, 
to secure perfect rest and quiet. In the event of an inability 
to employ antiseptic dressings, the treatment may be con- 
ducted by irrigation of the parts or the application of com- 
presses wet in the laudanum and lead-water solution. The 
inflammation which supervenes should be treated by the ad- 
ministration of appropriate constitutional remedies, and when 



DISLOCATIONS. 317 

suppuration occurs, by means of stimulants and tonics. It 
is of the utmost importance that perfect drainage of the 
wound should be accomplished in order to prevent the evil 
results liable to follow the inflammatory action. 

Old Dislocations Under the head of patliological char- 
acters, the changes which take place in the joint and sur- 
rounding structures in unreduced luxations of long standing 
were fully discussed. Considering these conditions, an im- 
portant question relates to the period of time at which the 
surgeon may, with propriety, institute efforts at reduction, 
and the manner in which the treatment should be conducted. 
Wiiile it may be impossible to fix any period arbitrarily in 
which reduction may be effected for the articulations in gene- 
ral, the rule laid down by Sir Astley Cooper may be accepted 
as a safe guide. It was his opinion that the limit of time in 
which it would be prudent to attempt reduction of the shoul- 
der-joint was three montlis after the receipt of the injury, 
and two months in cases of dislocation of the hip-joint. 
Cases are recorded in which dislocation of both shoulder- 
and hip-joints have been reduced at much longer periods 
after injury than those given above, as for instance, several 
cases of the shoulder-joint, by Dr. N. R. Smith and others, 
at periods varying from seven to ten and a half months, and 
a number of the hip-joint by Drs. Travers, Blackman, and 
others, from five to nine months. These cases are excep- 
tional, and occurred, no doubt, in persons of advanced age, 
or in those in whom the ligamentous and other tissues were 
in a very lax and elongated condition. Some years since, 
I was called upon to reduce a dislocation of the shoulder- 
joint of twenty-four months' standing, in a female of advanced 
years, in whom the tissues were so lax that it was quite easy 
to produce a recurrence of the displacement. In the gingly- 

27* 



318 ' DISLOCATIONS. 

moid form of articulations the period at which reduction 
may be accomplished, is still more limited, not extending 
usually beyond three or four weeks. 

The dangers which attend efforts at reduction in cases of 
long standing have been alluded to, and relate to the injury 
liable to be inflicted upon the structures about the joint, con- 
solidated by inflammatory deposits. Tiiose most important 
are the vascular and nervous trunks, which are involved in 
the mass of tissue and become thickened and contracted. 

No efforts at reduction should be attempted without first 
informing the patient of the dangers which attend the opera- 
tion. If it is deemed prudent to attempt reduction, prelimi- 
nary treatment, extending over a period of two weeks, should 
be instituted, the purpose of which is, by intelligently con- 
ducted movements to break up adhesions formed, and to 
overcome, to a certain extent, the rigid character of the 
structures involved. These movements may be assisted by 
manipulations and frictions with the hand, using at the same 
time soap liniment or some unctuous agent to soften and re- 
lax the tissues. At first, it is desirable to execute these 
movements but once in the twenty-four hours. Later tliey 
may be performed twice in the day. Purgatives and minute 
doses of mercury may be advantageously administered to 
avert inflammation and to assist in promoting absorption 
of plastic deposits. 

When the preliminary treatment is terminated the patient 
should be placed under the influence of an ansesthetic, and 
the attempt at reduction made with great care. The efforts 
should be conducted in such manner as to elongate the struc- 
tures so that the articular surface of the displaced bone may 
be placed upon a level with that of the opposing bone. The 
extension to accomplish this must be made slowly and de- 



DISLOCATIONS. 319 

Uberately; by tl)is manoeuvre alone the bone may be replaced, 
if not, other manipulations should be associated with it, with 
a view to return the bone through the opening in the liga- 
ment, which, it is natural to infer, will be much contracted in 
size, and the edges thickened and rigid. Violent and forci- 
ble efforts should be avoided, as they may result in the lace- 
ration of a bloodvessel, or nerve, or fracture of the bone. 
If the effort at reduction fails, the joint should, for the time 
being, be placed at rest, and evaporating lotions applied to 
control the inflammatory action liable to follow the manipu- 
lations performed. On its subsidence in a few days, another 
attempt may be made, the same precautions being taken. 
If the attempts made are without avail, and the functions of 
the joint are so impaired as to render the arm useless, or the 
pain, produced by the pressure of the displaced bone upon 
the nerves, unendurable, an operation for the establish- 
ment of a false joint by subcutaneous section of the bone, 
should be made in the manner as first suggested, and per- 
formed by the author in 1875, upon a patient at that time 
under his care. 

Excision of the end of the displaced bone may be per- 
formed in lieu of subcutaneous section, if the circumstances 
of the case make it desirable, although it is believed all that 
is needful can be accomplished by the latter with the great 
advantage of avoiding the dangers attendant upon the former. 

Rupture of the large artery or vein will be indicated by 
the sudden effusion of blood into the tissues surrounding the 
joint, and in case of the artery, cessation of the pulsation in 
the distal branches. 

The treatment of arterial rupture consists in making 
prompt pressure over the course of the vessel and the appli- 
cation of a ligature, as soon as possible, to the artery above 



320 DISLOCATIONS. 

the seat of rupture. Hemorrliage from a lacerated vein may- 
be controlled by pressure, and the absorption of the extra- 
vasated blood promoted by a firmly applied bandage. If, 
in the attempts at reduction, the bone should be fractured, 
the lesion should be treated as in fracture occurring under 
other conditions. 



Special Dislocations Head and Face. 

Lower Jaw — Temporo-maxillary Articulation — 
Double Artiirodia. — This articulation is formed by the 
glenoid fossa of the temporal bone and the condyle of the 
lower jaw, and is surrounded by capsular, external, and in- 
ternal lateral ligaments, with an accessory ligament, the 
stylo-maxillary. It has two synovial sacs, separated by an 
inter-articular fibro-cartilage. It is bounded in front by the 
erainentia articularis, externally by middle root of zygoma, 
and behind by the vaginal process of the temporal bone. 
The movements of the joint are gliding in character, with 
slight rotation. The muscles in relation with the joint are 
the external and internal pterygoid, temporal, and masseter. 
Dislocations of the joint may be complete, incomplete, uni- 
lateral, and bilateral. Rupture of the capsular ligament 
occurs only in the complete form. 

Causes — Dislocation may be produced by external vio- 
lence applied over the joint, causing unilateral displacement. 
It is more frequently the result of muscular action, when 
both condyles are dislodged, escaping, in the complete vari- 
ety, through a rent in the capsular ligament into the zygo- 
matic fossa (Fig. 163). 

In the incomplete dislocation they rest upon the eminentia 
articularis, the capsular ligament being stretched, and, as a 



DISLOCATIONS. 



321 



rule, not torn. The effect of muscular action, in producing 
luxation, is seen wlien the mouth is widely opened, the de- 
pression of the jaw causing the condyles to advance forwards 
upon the eminentia articularis. After reaching a certain 




point, spasmodic action of the fibres of the temporal and 
masseter muscles occurs, and the processes are thrown into 
the zygomatic fossa. Depression of the jaw, sufficient to 
produce dislocation, takes place in yawning, inordinate laugh- 
ter, the forcible introduction of a foreign body into the 
mouth, as an apple or billiard ball, or the separation of the 
jaws for the purpose of the extraction of teeth. I have been 
informed of a case occurring in this State, in which disloca- 
tion happened to a woman, who was, at the time, engaged 
in scolding her husband, the case resembling that reported 
by Dr. Dorsey. A case came under my observation, some 
years since, of a lady who suffered very often from luxation 
of the jaw in the act of singing, or in making any effort 
which required wide separation of the jaws. Her husband 



322 



DISLOCATIONS. 



was instructed in the method of reduction of the dislocation, 
and performed the operation for her relief. Dislocation may 
also occur as the result of indirect force, as in falls or blows 
upon tlie chin, the jaw being at the time depressed. 

Symptoms. — The symptoms of dislocation of the inferior 
maxilla are well marked. Pain, in some cases, is quite se- 
vere, due to the stretching of the ligaments and muscles in- 
volved in the luxation. Loss of function, deformity, and 
immobility are prominent symptoms. In the complete va- 
riety, the wide separation 
"=' ' of the jaws interferes with 

the functions of articula- 
tion, mastication, and de- 
glutition. The constant 
pressure of the rami upon 
the parotid glands excites 
them toincreased discharge 
of fluid, and the impaired 
action of the buccinator 
muscles permits the free 
escape of the saliva from 
the mouth. The depres- 
sion and projection of the 
jaw produce marked de- 
formity and give a very 
unpleasant, expression to 
the face (Fig. 164). The position of the condyle in the 
zygomatic fossa, combined with the muscular action, fixes the 
bone and renders it immovable. In unilateral displacement 
the symptoms are not so well defined, loss of function, de- 
formity, and immobility appearing in a modified degree. In 
the condition described originally by Sir Astley Cooper as 




DISLOCATIONS. 323 

subluxation of the jaw, the condyles glide beyond the posi- 
tion of the articular fibro-cartilages and become fixed upon 
the eminentia aiticularis. The symptoms which attend this 
condition are immobility of the jaw with slight separation 
of the teeth. 

Diagnosis Owing to the prominent character of the 

symptoms attending dislocations of the lower jaw, the diag- 
nosis is not difficult to be made, especially if an examination 
of the parts occurs soon after the accident. In the normal 
condition the condyle can be readily felt in its position, and 
its movement distinguished. When dislocation is present, a 
depression marks the former prominence, and the displaced 
condyles can be discovered in the zygomatic fossa. This ex- 
amination is facilitated by carrying a finger into the mouth, 
when counter-pressure on the outside being made, both 
processes, coronoid and condyloid, can be felt in their ab- 
normal positions. Luxation is to be distinguished from frac- 
ture of the neck of the condyle by the immobility of the jaw? 
the absence of crepitus and the abnormal position of the 
condyle in the zygomatic fossa. In unilateral dislocations 
the jaw is turned to the side opposite the joint affected, and 
an examination of the mouth shows a want of articulation 
of the teeth, especially of the anterior. In fracture of the 
condyloid neck, the jaw is turned toward the side injured, 
and the bone is movable. In a majority of instances, the 
history of the case will assist materially in determining the 
nature of the lesion. 

Prognosis — The prognosis is favorable, reduction being 
effected usually without difficulty and the functions of the 
articulation being unimpaired. Difficulty is sometimes ex- 
perienced in accomplishing reduction in cases of long stand- 
ing, although replacement has been effected at the expiration 



324 DISLOCATIONS, 

of three and four months subsequent to the occurrence of 
the dislocation. In luxations which remain unreduced, the 
symptoms gradually disappear, the bone and surrounding 
liofamentous and muscular structures accommodatinor them- 

o o 

selves to the new conditions, so that the deformity and disa- 
bility are largely, though not entirely, removed. 

Treatment. — The manipulations necessary to obtain re- 
duction consist in drawing the jaw slightly forward, so as 
to relieve the condyle from its fixed position, elevation of the 
chin, effecting, by the same movement, depression of the 
angles, and pushing the bone backward, the condyle, slipping 
over the eminentia articularis, into its place. 

This last movement is usually accomplished by the action 
of the temporal and masseter muscles, which, when the pro- 
cess is placed upon the eminentia articularis, suddenly con- 
tract and throw it into the glenoid fossa. 

The surgeon may perform these manipulations in the fol- 
lowing manner. The patient being seated upon a low chair, 
with the head well supported by an assistant, is, if necessary, 
placed under the influence of an anaesthetic. The surgeon 
having wrapped the thumbs with thick compresses for pro- 
tection, stands in front of the patient and introduces them 
into the mouth, carrying them back to a position between 
the three molar teeth, and grasps the body of the jaw around 
the base with tlie remaining fingers of each hand, extending 
them backward to the angle (Fig. 165). Having obtained 
a firm hold of the jaw, it is drawn slightly forward, the chin 
is elevated, the angles depressed, and condyles pushed back 
into place or permitted to be drawn back by the muscular 
action. If the muscles are not too much relaxed by the an- 
aesthetic, the condyles return to their position in the glenoid 
fossa with an audible snap. Tiie thumbs of the surgeon 



DISLOCATIONS. 325 

should be quickly removed from between the teeth as soon 
as he recognizes the beginning of the movement of replace- 
ment, lest they be caught and injured by the powerful con- 
traction of the muscles. 

Fiff. 165. 




Reduction maybe also effected by the introduction of wedges 
of soft pine wood, between the molar teeth, which, being used 
as levers, depress the angles of the jaw and permit the con- 
dyles to return to place. Corks, secured by pieces of cord, 
may be used to accomplish the same purpose. The method 
of M. Nelaton consisted in placing the thumbs on the nape 
of the neck, the surgeon standing behind the patient, and 
making pressure on the coronoid processes, through which 
manipulation the jaw is pushed forward and the angles de- 
pressed, so that the condyles can pass over the articular emi- 
nence. The late Prof. Gross succeeded in reducing bilateral 
dislocations, which had resisted other plans of treatment, 
28 



326 DISLOCATIONS. 

by replacing one condyle at a time, in this manner overcom- 
ing the muscular tension which existed and defeated previous 
attempts at reduction. 

A fall upon the buttocks, or backward down a flight of 
stairs, has been known to effect reduction in cases of com- 
plete dislocation of the jaw. As methods of treatment, 
however, they are not to be commended. 

Unilateral luxation is reduced in the same manner as those 
of the bilateral variety. Sub-luxations are easily relieved 
by drawing the jaw forward and downward. Subcutaneous 
sections of the temporal, masseter, and external pterygoid 
muscles may be performed to assist in accomplishing reduction 
in cases of old luxations which resist the ordinary methods. 

After replacement of the displaced condyles, Rhea Bar- 
ton's bandage should be applied for the purpose of keeping 
the articulation at i-est for ten days to two weeks, the patient 
meanwhile feeding upon liquid diet. 

Patients of feeble constitutions sometimes suffer from an 
elongated and relaxed condition of the ligaments of the 
temporo-maxillary articulation, which permit the condyles 
to slip back suddenly fi'om their position upon the articular 
eminences, during movements of the jaw, giving rise, in this 
way, to a crackling noise. Relief is afforded in these cases 
by the administration of tonics, as iron and quinine, and the 
repeated application of small blisters over the position of the 
articulation. Dislocation is liable to occur in these cases, 
and care should be taken to guard against its occurrence in 
depression of the jaw, as in the act of yawning. 

Instances of congenital dislocation have, been reported in 
connection with this articulation. 

Vertebral Articulations — Amphi-Arthrodial. — 
The vertebral column is a strong, fiexuous column, com- 



DISLOCATIONS. 327 

posed of separate segments of bone fastened together by the 
anterior and posterior common ligaments, with inter-verte- 
bral disks of fibro-cartilage between the bodies, ligamenta 
subflava between the laminae, capsular around the articula- 
tions and inter-transverse, inter-spinous and supra-spinous 
between the processes. Tiie peculiar form of articulation be- 
tween the atlas and occipital bone, and atlas and axis, where- 
by a greater latitude of movement is permitted, changes some- 
what the arrangement of the ligaments and character of the 
articulation, making the former a double arthrodia and the 
latter a lateral ginglymoid with a double arthrodia between 
the articular surfaces. The ligaments of the vertebral col- 
umn are very strong, and bind tlie different vertebrae to- 
gether in such manner as to render their separation impossi- 
ble without the application of the greatest violence. The 
portion of the column most liable to suffer from luxation is 
the cervical, owing to its greater range of movement. Dis- 
location, not associated with fracture, is extremely rare in 
the dorsal region, and it is believed that simple dislocation 
of the lumbar vertebros never occurs. Dislocation of the 
vertebra? may be complete and incomplete — unilateral or bi- 
lateral — and the direction of the displacement may be for- 
ward or backward. In complete luxations, the anterior 
and posterior common ligaments with the inter- vertebral 
substances are torn. The anterior common ligament usually 
escapes rupture, being detached for some distance above and 
below ; the cord may be contused or completely severed and 
extravasation of blood may occur in the canal. The lodg- 
ment of the cord in the vertebral canal, and the great liabil- 
ity to the application of pressure upon it by slight encroach- 
ments upon the calibre of the canal, render displacements of 
the vertebrae very grave accidents. 



328 DISLOCATIONS. 

Causes The causes of dislocation of the vertebrae are, as 

a rule, the direct application of violence to the portion in- 
volved, the rest of the column being fixed, as in falls, crushes 
-from falling walls or banks of earth, or in railroad accidents, 
where the body, in a state of extreme flexion or extension, is 
caught between timbers and firmly held. In the cervical 
region^ especially in the atlo-axoid articulation, dislocation 
sometimes occurs as the result of muscular action. At this 
articulation luxation may occur in various ways. It may 
result after fracture of the odontoid process or rupture of the 
transverse ligament. In some instances, when the atlas and 
axis are widely separated, as may be accomplished by the 
very reprehensible practice of lifting children up by grasping 
the sides of the head with the hands, the odontoid process 
slips from behind the transverse ligament and a luxation 
occurs, causing, sometimes, instant death. 

Violent and extreme rotation of the head upon the neck may 
cause rupture of the capsular ligaments of both articulations 
and displacement of the atlas obliquely across the axis, a move- 
ment which has been practised by executioners upon crimi- 
nals undergoing the sentence of death. Rupture of the liga- 
ments of one articulation may occur, producing much less 
displacement. 

Luxations at the occipito-atloid articulation occur as the 
result of force directly applied, producing extreme flexion of 
the head and neck upon the chest. In the articulations be- 
low the atlo-axoid, displacements may be produced by force 
applied with the neck in extreme flexion or in the straight 
position, the vertebra above being displaced anteriorly while 
that below remains fixed. 

Owing to the very immovable character of the articula- 
tions of the dorsal region of the column, luxation, uncom- 



DISLOCATIONS. 329 

plicated with fracture, rarely occurs, especially in the upper 
tliree-tburths. In the lower fourth, between the ninth ver- 
tebm and first lumbar, where a greater amount of mobility 
exists, simple dislocations take place more frequently and 
are caused by the application of direct violence, producing 
extreme flexion of the column at this point. Luxations of 
the lumbar vertebrae would occur, if at all, as a result of the 
force applied in the same manner. In dislocations of the 
various regions of the vertebral column, the displacement 
of the vertebra? may be forward, backward, or lateral. 

Symptoms. — The symptoms vary in the different regions 
of the column and in accordance with the character of the 
injury. Pain is usually a very marked symptom, and is 
caused by pressure exerted by the displaced bone, as well as 
the tension to which the structures are subjected. 

In a case of luxation between the fourth and fifth cervical 
vertebra) accompanied by fracture, reported by Dr. S. W. 
Gross, the pain was severe and continued until the death of 
the patient, nearly two and a half months after the accident. 

The contusion of the parts accompanying the accident is 
liable to produce pain, which would be increased on move- 
ment. Loss of function is very distinct, the patient being 
unable to perform the movements of flexion, extension, or ro- 
tation. In luxations involving the cervical region deformity 
and immobility can be recognized, the head being flexed or 
extended as the displacement is backward or forward. In 
the dorsal or lumbar regions these symptoms are less distinct. 
Paralysis is a symptom common to both fracture and dislo- 
cation, and is, therefore, not distinctive. It varies in accord- 
ance with the degree of pressure, and the point at which the 
pressure is exerted. If the point of pressure is above the 
origin of the phrenic nerve, immediate death may occur by 

28* 



330 DISLOCATIONS. 

reason of the interference with the respiratory function of 
the diaphragm. Pressure in the dorsal and lumbar regions 
is followed by paralysis involving sometimes the external 
muscles of respiration, the bladder, rectum, and lower ex- 
tremities. 

Diagnosis In dislocations occurring in the cervical re- 
gion, the symptoms are sometimes sufficiently distinct to free 
the diagnosis from great difficulty. In other portions of the 
column they are ordinarily so obscure as to prevent the for- 
mation of a positive opinion as to the exact nature of the 
lesion present. 

The symptoms of pain, loss of function, and deformity 
accompany fractures of the vertebrae as well as dislocations, 
and are, therefore, not distinctive. Immobility is difficult 
to distinguish in any region of the column, with the excep- 
tion, possibly, of the cervical. The detection of a sulcus or 
depression over the site of the luxation may assist in deter- 
mining the nature of the accident ; it exists, however, in 
fractures, and I have observed the condition in cases of con- 
tusion of the spine, in which the speedy recovery of the 
patient left no doubt as to the nature of the injury. In dislo- 
cation of the upper cervical vertebrae, inspection of the pos- 
terior wall of the pharynx may assist in detecting the 
displacement. In dislocations, the occurrence of paralysis is 
usually very prompt, while in fractures it may take place at 
once, as the result of pressure produced by the fragments, 
or later from pressure exerted by clots or inflammatory de- 
posits. Pressure by clots of blood is not so liable to occur 
in dislocations as in fractures. 

Prognosis. — The prognosis in luxations of the vertebrae 
is extremely unfavorable, deatli occurring in a majority of 
cases immediately or within a short time following the re- 



DISLOCATIONS. 331 

oeipt of the injury. AVlien a fatal result does not occur im- 
mediately, the patient may succumb finally to the exhaustion 
produced by pain, and, possibly, the suppuration occurring 
from large bed sores. In some cases the function of respira- 
tion is seriously involved, by reason of pressure upon the 
cord in the cervical and lower dorsal regions, which gradu- 
ally increases, producing a fatal result. Paralysis, more or 
less complete in character, is liable to follow dislocations of 
the vertebrie and complicate the case. Instances are recorded 
of recovery after dislocation, in which the disability has not 
been very great, and there are still other cases in which re- 
duction has been effected and permanent recovery estab- 
lished. 

Treatment — The great danger of precipitating a fatal ter- 
mination by sudden compression of the cord in the efforts to 
effect reduction has contributed largely to the adoption of 
the expectant plan of treatment in dislocations of the ver- 
tebrie. The successful results which have attended the ef- 
forts at reduction in cases of luxation in the cervical region, 
have encouraged surgeons in the opinion that in certain in- 
stances in which the nature of the displacement is well- 
defined, and the symptoms urgent, attempts should be made 
to accomplish reduction in cases involving this region. In 
all cases it should be understood that a fatal result may ac- 
company the effort, a result which is otherw^ise inevitable. 
If it is decided to attempt reduction, a very careful exami- 
nation of the parts should be made to obtain, as near as pos- 
sible, an exact knowledge of the nature of the luxation. 

The manipulations necessary to obtain reduction should 
be carefully considered, and should be made with the utmost 
caution and precision. The patient should be placed under 
the influence of an anaesthetic, so as to secure complete re- 



•332 DISLOCATIONS. 

laxation of the muscular system, and overcome all resistance. 
Extension should be slowly and steadily made in the line of 
the vertebral column, the head being firmly grasped by tlie 
hands of the surgeon, placed beneath the occiput and base 
of the lower jaw\ Counter-extension should be made from 
the shoulders, which are securely fastened to the table, upon 
which the patient rests by folded sheets crossed in front and 
behind, or they may be held firmly by two assistants grasp- 
ing the summits. The operator being on a level with the 
shoulders may place his feet on the summits and in this man- 
ner make counter-extension while extension is being made 
with his hands. In anterior displacements the head should 
be drawn cautiously backw^ard so as to unlock the parts, then 
upward and finally forward, in this manner placing the ver- 
tebrae in sucli position that a return to place will occur. In 
posterior luxations the manipulations should be the reverse. 
Pressure and counter-pressure may be employed in combina- 
tion with extension and may prove of great assistance. Some- 
times pressure may be practised successfully by introducing 
the finger through the mouth into the pharynx, and in this 
way pushing the displaced bone into place, whilst extension 
is maintained. In late^-al luxations rotation should be made 
at the same time w^ith extension. 

In dislocation of the vertebrae in the dorsal or lumbar re- 
gion, accompanied by paralysis, the patient should be placed, 
if possible, upon a w^ater bed, a cheap form of which can 
be prepared as described on page 130; if this cannot be pro- 
cured, he should rest upon a firm mattress, and great care 
should be exercised to prevent the formation of bed sores. 
Careful attention should be given to the bladder, the cathe- 
ter being used at least twice in the day, to evacuate its con- 
tents. The bow^els should be relieved at stated times by ene- 



DISLOCATIONS. 333 

mata, if necessary. Wlien involiintary escape of the urine 
or feces occurs, measures should be taken to protect tlie bed 
by use of the urinal and masses of oakum, in which the feces 
may be received. 

A condition designated as sub-luxation of the vertebrae is 
described as occurring as the result of violence, inflicted over 
the region involved, most frequently the dorsal, or of force 
transmitted through a fall upon the buttocks. The effect of 
the violence is to cause a ru[)ture of the ligaments and sepa- 
ration of the spinous processes. Severe concussion usually 
accompanies the injury with, sometimes, symptoms of com- 
pression of the cord and partial paralysis. The treatment 
consists in rest in the recumbent position upon a firm mat- 
tress, with the administration of remedies internally, and, 
if needed, local applications to allay inflammatory action. 

Hyoid Bone In youth, the cornua of this bone are con- 
nected to the body by cartilaginous surfaces and held together 
by ligaments fonning an articulation. In middle life, con- 
solidation usually occurs between the body and greater cor- 
nua, and in old age all of the segments become united, form- 
ing a single bone. Dislocation of the greater cornua can 
only occur in early life, and instances recorded as having 
taken place after that period, have been associated probably 
with abnormal conditions in the articulation, as in one of the 
cases reported by Dr. Gibb, of London. 

Causes Luxation of the cornua of the hyoid bone may 

be the result of external violence, as that applied to the neck 
by the hand, or of muscular action, the body of the bone 
being fixed, while the muscles inserted into the upper bor- 
der of the cornua act with undue violence. 

Symptoms — The symptoms attending dislocation of the 
cornua of the bone are not very distinct. In one of the 



334 DISLOCATIONS. 

cases reported by Dr. Gibb, the patient perceived, at the 
time of the occurrence of the displacement, a sudden click 
over the region of the articulation, and experienced the sen- 
sation of something sticking in the throat. 

Diagnosis The absence of any well-defined symptoms 

renders the diagnosis difficult. Luxation may be suspected 
if the symptoms are present which occurred in the case above 
alluded to. The differential diagnosis between fracture and 
dislocation is difficult to make. 

Prognosis. — In dislocations, the result of external vio- 
lence, the injury to the larynx may be so severe as to render 
the prognosis very doubtful. In simple luxations, or in 
those due to muscular action, the termination is usually 
favorable. The tendency to the recurrence of displacement 
is observed to exist in some cases. 

Treatment Keduction is accomplished by extending the 

head upon the neck, so as to render the muscles inserted into 
the lower border of the hyoid bone tense, and then relaxing 
those inserted into the upper border by depressing the jaw. 
This movement, conjoined with pressure, is effective in ob- 
taining reduction. • 

Ribs and Costal Cartilages — Costo-vertebral 
Articulations. — The articulation of the head of the ribs 
with the bodies of the vertebrae and the neck and tubercle with 
the transverse processes, constitute a series of angular gingly- 
moid joints in the former, with arthrodial articulations in the 
latter. Tiie anterior costo-vertebral or stellate, wi1:'h the cap- 
sular and interarticular ligaments bind the heads of the ribs 
securely to the contiguous margins of the bodies of the verte- 
brae, while the anterior, middle, and middle costo-transverse, 
witii tlie capsular, fasten tlie neck and tubercle equally secure 
to the transverse processes. This double attachment of the 



DISLOCATIONS. 335 

extremity of the rib to the vertebra renders the articulations 
very strong, and this fact, combined with the protected posi- 
tion occupied by tliem, makes simple dislocation at this point 
almost an impossibility. Tn nine cases of costo-vertebral 
luxations collected by Mr. Poland and quoted by Prof. 
Agnew, six were uncomplicated and three accompanied by 
fracture or other injury. In one case under the care of Prof. 
Agnew fracture accompanied the dislocation. 

CosTO-cnONDKAL JUNCTION The junction of the carti- 
lage with the rib cannot be properly described as an articula- 
tion ; the cartilages are simply continuous with the osseous 
structures of the ribs, beino; received in cup-shaped depres- 
sions on the end of the rib and covered by an expansion of 
the periosteal membrane. Dislocation, or rather separation 
at this junction, is extremely rare, although a number of cases 
have been observed and recorded. The case related by Sir 
Charles Bell is most remarkable, in which all of the ribs 
were separated from their cartilages as the result of violent 
compression of the thorax. 

Chondro-sternal Articulations These articula- 
tions are arthrodial, and are united by anterior, posterior, and 
capsular ligaments with synovial membranes between all ex- 
cept the first ; the second and third have two each while the 
remaining have one each. A dislocation occurring at these 
articulations, although rare, occurs more frequently than 
those at the costo-vertebral joints. The late Prof. Gross 
reports having seen several cases of the kind. 

Chondral Articulations. — The articulations occur- 
ing between the cartilages of the sixth, seventh, eighth, and 
ninth ribs are also arthrodial, and are enveloped by thin cap- 
sular ligaments lined by synovial membranes, and strenghened 
externally and internally by ligamentous fibres. A few in- 
stances of luxation of these joints have been reported. 



33G DISLOCATIONS. 

Causes The cause of dislocation of the ribs and costal 

cartilages is external violence, applied directly or indirectly. 
Direct force, as in falls, blows, or crushes in railroad acci- 
dents may produce luxation at either of the joints. Indirect 
violence, as in severe compression of the thorax, tlie body 
being caught between opposing objects, is liable to cause 
separation at the costo-chondral or costo-sternal articulations. 
The force applied in either way must be very severe in 
character to cause separation at joints so firmly united and 
protected, and is frequently productive of serious complica- 
tions in injury to the organs contained within the thorax. 

Symptoms In costo-vertebral luxations there are no 

symptoms which can be regarded as distinctive. Pain may 
be present as in all severe injuries, and pain experienced 
during the acts of respiration may be the result of muscular 
contusion or fracture. Symptoms somewhat rnore promi- 
nent attend chondral luxations — as pain, deformity, preter- 
natural mobility, and, in some instances, dyspnoea. Crepitus 
is sometimes lieard over the position of the articulation. 

Diagnosis — To determine the exact nature of the dis- 
placement in costo-vertebral dislocation is regarded as im- 
possible, on account of the absence of well defined symptoms, 
and the position of the parts which interferes with a satisfac- 
tory examination. The facility witli which the parts can be 
examined in chondral dislocations and the more prominent 
character of the symptoms, render the diagnosis less difficult. 

Prognosis — In all forms of dislocations involving the ribs 
or cartilages, the prognosis is unfavorable, owing to the 
severe violence accompanying the injury. Costo-vertebral 
luxations are, as a rule, followed by fatal results, whilst 
those of the cartilages, if the complications a,re not too 
serious, may result in recovery. 



DISLOCATIONS. 337 

Treatment. — Efforts at reduction may be made in disloca- 
tion of the cartilages by extending the trunk, and making 
pressure over the displaced cartilage. Drawing back the 
shoulders may assist in the attempt. The inhalation of 
ether will contribute to success in reduction by the expan- 
sion of the walls of the chest caused by the deep inspiration 
taken by the patient. In all varieties of luxation a broad 
bandage should be firmly applied about the chest to afford 
support, and limit the extent of the respiratory movements. 
The conditions resulting from the contusion and other injuries 
of the parts should be treated upon general principles, the 
indications being to control by appropriate remedies the 
inflammatory action liable to supervene. In costo-vertebral 
luxations the parts should be supported by compresses and a 
broad bandage, as in fractures, and accompanying complica- 
tions treated as above indicated. 

Sternum and Ensiform Cartilage The sternum 

consists of three pieces, manubrium, gladiolus, and ensiform 
process or cartilage, united by articulations of the arthrodial 
variety, w^hich are covered by expansions of the anterior 
and posterior costo-stenial ligaments. Authorities differ as 
to the character of the articulation existing between the 
different portions of the bone. According to Maisonneuve 
they are fibrous in character in about twenty-five per cent. 
of cases, and arthrodial in the remaining seventy-five per 
cent. Dislocation occurs most frequently between the 
manubrium and gladiolus, rarely between the gladiolus and 
ensiform process. A number of cases of dislocation between 
the manubrium and gladiolus have been collected and ana- 
lyzed by Malgaigne, Mr. Poland, of London, and Dr. Brinton, 
of this city. Ten by Malgaigne, of which number five 
died ; fourteen by Poland with six deaths, five recoveries, and 
29 



338 DISLOCATIONS. 

three in which the result is unknown ; tliirteen by Brinton 
with seven deaths and six recoveries. Two cases of luxa- 
tion of the ensiforin process have been recorded by Malji^aigne. 

Cause Tiie cause is great violence applied directly, as 

by a blow, or indirectly by extreme flexion of the body, as 
in a crush by the debris of a falling wall. 

Symptoms. — The most prominent symptom is deformity, 
which is readily seen on examination of the bone. Disloca- 
tions of the ensiform cartilage are accompanied by pain in 
the stomach, dypsnoea, and obstinate vomiting. In luxation 
of the manubrium the gladiolus is the portion displaced, and 
passes behind or in front of the manubrium. It takes the 
former position when the force is applied directly, and the 
latter when the separation is the result of extreme flexion of 
the body. Pain, dyspnoea, and crepitus heard during respi- 
ration, are also present in most cases. 

Diagnosis The displacement of the bone is detected on 

inspection, and its position may be determined by examina- 
tion. It is to be distinguished from fracture by fixing the 
position of the articulation and ascertaining the relation of 
the point, at which displacement occurs, to it. 

Prognosis — The complications which so frequently attend 
dislocation of the sternum render the prognosis unfavorable. 
In simple cases it may be regarded as favorable, although, in 
many instances, reduction cannot be effected. 

Treatment Notwithstanding the unsuccessful results 

which have accompanied efforts at reduction, tliey should be 
undertaken in all cases. The patient should be placed on 
his back, bent over a number of hard cushions or pillows, 
so as to extend the body and make the thorax very convex 
anteriorly. While in this position, pressure should be made 
over the displaced bone, so as to force it downward and 



DISLOCATIONS. 339 

backward. When urgent symptoms are present, caused by 
pressure of the dislocated bone, a small elevator may be 
introduced subcutaneously into the bone, for the purpose of 
lifting it into position. 

In dislocation of the ensiform process reduction may some- 
times be etfected by pressing the finger beneatli it and raising 
it into place. In one of tlie cases reported by Malgaigne, 
a small incision was made into the abdominal cavity, by the 
side of the cartilage, and it was then elevated into position 
with a hook. Whether reduction is effected or not, a broad 
bandage should be applied around the chest in all varieties 
of dislocations, and measures should be taken to treat the 
complications present. 

Upper Extremity. 

Dislocations of the upper extremity may be divided into 
those of the shoulder, including the clavicle and scapula, 
humerus, radius and ulna, carpus, metacarpus, and phalanges. 

Shoulder The shoulder is formed by the clavicle and 

scapula united at the acromio-clavicular articulation. 

Clavicle. — The clavicle is placed between the manubrium 
of the sternum and acromion process of the scapula, attached 
to the former by the ligaments of the sterno-clavicular articu- 
lation, and to the latter by those of the acromio-clavicular. 
Dislocations may occur at either joint, or, in rare instances, 
at both simultaneously. 

Sterno-clavicular Articulation This articulation 

is arthroidal in character, and is formed by the sternal end of 
the clavicle, the u{)per and lateral surfaces of the first piece 
of the sternum, and the cartilage of the first rib. The liga- 
ments of the joint are the anterior and posterior sterno- 



340 DISLOCATIONS. 

clavicular, interclavicular, costo-clavicular or rhomboid, and 
interarticular fibro-cartilage. This joint bears a very im- 
portant relation to the shoulder, being the centre of its 
movements, and admits of motion upward, downward, for- 
ward, backward, as well as that of circumduction. The end of 
the clavicle and interarticular fibro-cartilage glide upon the 
articular surface of the sternum. Dislocations at this articu- 
lation are much less frequent in occurrence than at the 
acromio-clavicular joint, the explanation being found, pro- 
bably, in the protected position it occupies, and the immu- 
nity it enjoys by reason of the manner in which it receives 
the application of force. Males suffer from the accident 
more frequently than females. The displacement of the end 
of the clavicle maybe in i\\% forward, backward, ov upward 
direction, and may be complete or incomplete. 

Causes In the production of luxation of the sternal end 

of the clavicle the force may be applied directly or indirectly, 
causing the forward, backward, or upward displacement. 

Dislocation ybr«^;arc? is the result, usually, of force applied 
to the shoulder when it is drawn backward, as may occur in 
falls. The end of the bone is driven outward and through 
the rupture of the ligaments forward upon the front of the 
sternum, the interarticular ligament generally accompany- 
ing it. 

The backward displacement may be caused by violence 
applied directly over the sternal extremity, by which it is 
forced from its position backward, as when it is the result of 
blows over the part. Force applied to the shoulder when it 
is drawn forward is transmitted to the articulation in such 
manner as to drive the end through the posterior ligaments 
backward, and then forward to a position somewhat behind 
the sternum. 



DISLOCATIONS. 341 

Luxation upward results usually from violence applied to 
the top of the shoulder, causing a depression of the scapula 
downward and inward, and pushing the sternal extremity 
upward through the ligaments upon the interclavicular notch. 

Symptoms The symptoms vary in accordance with the 

character of the displacement. In all varieties, pain, loss of 
function, and deformity are present. 

In the/orw-'arc? dislocation, pain is usually not very marked; 
it is increased on making attempts to move the arm, the 
function of which is interfered with by reason of the luxa- 
tion. Deformity is very prominent, and is caused by the 
displaced end of the clavicle on the anterior surface of the 
sternum, a deep sulcus at the position of the joint, produced 
by the separation of the articular surfaces, and a depression 
of the shoulder. The sternal origin of the sterno-cleido- 
mastoid muscle is drawn tense and rendered very promi- 
nent, and the head of the patient is turned toward the 
affected side. 

The backivard dislocation presents, in addition to those 
mentioned above, as belonging to the forward luxation, 
symptoms which are characteristic of the injury. The head 
of the bone is lodged behind the sternum, leaving a depres- 
sion in the situation of the joint. Generally the pressure 
exerted by the dislocated bone upon the trachea, oesophagus, 
and bloodvessels in this region of the neck is sufficient to 
cause considerable dyspnoea, dysphagia, and cerebral con- 
gestion. The loss of function is very marked, the move- 
ments of the arm being completely lost. The pain is fre- 
quently very distressing. 

In the upward dislocation the displaced bone occupies a 
position upon the top of the sternum, obliterating partially 
the interclavicular notch. The shoulder is depressed and 

29* 



342 DISLOCATIONS. 

carried forward, approacliing nearer to the median line of 
the body than is normal. The space between the bone and 
cartilage of the first rib is notably increased with a vacuity 
at the site of the joint. Loss of function is not so marked 
as in the other forms of luxation, the movements of the arm 
being somewhat less restricted. The sternal origin of the 
sterno-cleido-mastoid muscles is stretched over the end of 
the displaced bone and rendered tense. 

Diagnosis A careful inspection of the parts, with a 

study of the symptoms presented, will enable the surgeon to 
make the diagnosis w^ithout difficulty. With the finger, the 
border of the bone can be traced, and the position of its dis- 
placed extremity fixed whether in front, above, or behind 
the sternum. 

Prognosis. — The difficulty of maintaining the displaced 
bone in accurate position after reduction until repair occurs, 
by means of any dressing or apparatus yet devised, makes 
the prognosis as to restoration of the parts to the normal 
position, unfavorable. Fortunately, the function of the 
shoulder and arm are not greatly affected, for their move- 
ments of the former are in time, to a great degree, re-estab- 
lished. The deformity remains. 

Treatment Owing to the peculiar formation of the ar- 
ticular surface of the sternum, its shallow character, and 
the manner in which the end of the clavicle is received into 
it, great difficulty is experienced in retaining the displaced 
bone in place until the rupture of the ligamentous tissues is 
sufficiently repaired. The displacement of the interarticu- 
lar cartilage frequently complicates the condition and inter- 
feres with proper adjustment of the articular surfaces. 

In the forward dislocation reduction may be effected by 
drawing the shoulders forcibly backwards, tlie knee of an 



DISLOCATIONS. 343 

assistant being placed between the scapulae of tlie patient, 
seated on a stool or chair, while the displaced bone is pressed 
into position by the surgeon. Another method consists in 
placing one hand closed into the axilla, while with the other 
the elbow is grasped, the arm pushed upward against the 
acromio-clavicular articulation, and the shoulder carried up- 
ward, outward, and backward ; the forearm is then brought 
across the chest, the fingers resting upon the opposite clavicle. 
This movement may be assisted by manipulation, the dis- 
placed extremity being pushed slightly upward and back- 
ward. Desault's apparatus (Fig. 67) should be now applied 
to hold the parts in position, a large pad being placed over 
the articulation to afford pressure and support. In place of 
this dressing. Fox's apparatus for fractured clavicle (Fig. 
107), Yelpeau's bandage (Fig. 66), or the plaster dressing 
(Fig. 113), may be employed. Frequent inspection of the 
parts should be made to see that the reduction is maintained, 
and the dressings should remain in position from ten to 
twelve weeks. 

The displacement of the bone in the dislocation hachwara 
may be overcome by the same manipulation as that practised in 
effecting reduction in the forward luxation. The method in 
which the knee is placed between the scapulae will probably 
be most effective. Assistance may be rendered by drawing 
the arm away from the body at right angles. Recurrence 
of the displacement may be prevented by the application of 
the posterior figure-of-8 bandage, a long, thick, compress be- 
ing placed between the scapulae. A splint, extending from 
one shoulder to the other, may be placed over the compress, 
and the figure-of-8 bandage then applied, as employed by 
Mr. De Morgan. 

In an exceptional case of backward dislocation, which re- 



344 DISLOCATIONS. 

sists all efforts at reduction, and in which the pressure ex- 
erted by the displaced bone upon the structures of the neck 
causes grave symptoms, it may be necessary to resort to tiie 
operation of excision of the luxated extremity, as performed 
by Mr. Davie, of Bungay, in a case wiiere the dislocation 
was caused by deformity of the spine. In this variety of 
luxation, the clavicle was forced from its articulation by the 
gradual advancement forward and depression of the shoul- 
der. The pressure upon the trachea and oesophagus caused 
great dyspnoea and serious difficulty in deglutition. Reduc- 
tion being impossible by reason of the deformity of the ver- 
tebral column and pathological changes which had occurred 
in the articulation, excision was performed with the result 
of relieving the condition at once. 

Reduction in the upward variety of dislocation is accom- 
plished by drawing the shoulder upward and outward, while 
the displaced end of the clavicle is pressed into the articular 
cavity. Retention may be obtained by the application of 
Desault's or Fox's apparatus, a pad being firmly secured 
over the articulation by adhesive strips or bandages ; a plas- 
ter jacket may be advantageously employed. Great diffi- 
culty is experienced in retaining the luxated bone in posi- 
tion, and defective repair usually follows treatment. 

Acromio-Clavicular Articulation This joint is 

formed between the outer flattened extremity of the clavicle 
and the upper edge of the acromion process of the scapula, 
likewise flattened — the articulatino- surfaces on each beinor 
small oval facets ; that on the clavicle is directed obliquely 
downward and inward. The ligaments which serve" to unite 
the clavicle to the acromion and coracoid processes are the 
superior and inferior acromio-clavicular, the coraco-clavicular 
(conoid and trapezoid), and interarticular fibro-cartilage. 



DISLOCATIONS. 345 

The ligaments are very strong and fasten tlie clavicle firmly 
to the scapula. The form of the articulation permits of a 
gliding movement of the clavicle on the acromion process and 
a rotation of the scapula upon the clavicle forward and back- 
ward. 

Dislocations of the clavicle may occur in three directions 
— upward above the acromion process, downward and back- 
ward beneath it, and downward and forward beneath the 
coracoid process. Of these different varieties, the first oc- 
curs most frequently, owing to the direction of the articular 
surface upon the clavicle. These displacements may be 
complete or incomplete. In the complete upward disloca- 
tion, all, or part of the fibres of the coraco-clavicular liga- 
ments may be torn as well as those of the acromio-clavicular. 

Causes Severe external violence, applied directly or 

indirectly, is required to produce luxation at this joint. 
Direct force may be received upon either the clavicle or 
scapula, and indirect force may be transmitted from the 
sternum through tlie clavicle to the articulation, or from the 
elbow through the humerus to it. The violence necessary 
to produce the luxation is usually so great as to inflict injury 
upon the surrounding structures, causing severe contusions. 

Symptoms. — The most characteristic symptom of the dif- 
erent forms of dislocation occurring at this articulation is de- 
formity, varying in accordance Avith the position taken by the 
displaced bone. Loss of function, affecting the arm, is more 
marked in the upward and backward than in the forward 
displacement. Pain, discoloration, with more or less swell- 
ing, accompany all varieties of the luxation. 

In the upward dislocation, a small, hard tumor is seen 
and felt over the acromion process, which disappears on ele- 
vation of the arm and returns when the limb is depressed. 



346 DISLOCATIONS. 

The head is turned towards the injured shoulder, and the 
arm rests against the body, the patient being unable to 
carry the hand to the mouth. 

The dowmcard luxation is characterized by a very 
marked prominence of the acromion process, and at the same 
time an inward projection toward the sternum. The disa- 
bility of the arm is shown in the inability of the patient to 
execute voluntary movements with it. 

\w\\\it forward dislocation, the position of the clavicle be- 
neath the coracoid process renders" both this process and the 
acromion very prominent, and at the same time the sternal 
end of the clavicle is tilted up — the scapula is inclined 
downward and forward ; the movements of the arm are 
iVee, except in the upward and inward direction. 

Diagnosis. — The symptoms in each variety of dislocation 
are so distinct that no difficulty is encountered in making 
the diagnosis. When inspection does not reveal the position 
of the displaced bone, tlie finger can be passed over its 
border, tracing it to the abnormal position occupied. Ex- 
amination througli the axillary space will assist in discerning 
the displaced bone in the dislocation forward, under the 
coracoid process. 

Prognosis Owing to the peculiar formation of the 

acromio-clavicular articulation and the almost complete 
laceration of the ligaments in dislocation, the prognosis as 
to permanent restoration of the displaced bone is unfavor- 
able ; as stated by the late Prof. Gross, it is fortunately 
a matter simply of deformity and not of utility, as the 
functions of the parts involved are in a great measure 
gradually restored. 

Treatment. — The reduction in the different forms of acro- 
mio-clavicular luxation is to be effected in the same manner 



DISLOCATIONS. 3-17 

as in those of" tlie sterno-claviciilar articulation. In the 
vpuuird dislocation the displaced bone can be readily re- 
turned to its normal position by drawing the shoulders up- 
ward and backward, the movement being accomplished by 
placing the knee between the scapula? and grasping the 
shoulders with the hands, while the patient is seated upon a 
chair. Retention may be obtained by placing a piece of 
sheet-lead, enveloped in the folds of a thick compress, over 
the articulation, and securing it in place, as well as fixing 
the position of the arm by the application of the spica ban- 
dage of the shoulder (Fig. 52), or Desault's or Velpeau's 
bandage. Additional support may be given to the lead 
compress by passing a broad strap over it, and then carry- 
ing this under the elbow and securing it by another strap 
around the chest. The tourniquet of Petit may be applied 
in the same manner as suggested by Laugier. 

The downward luxation may be reduced in the manner 
described above, the elbow being carried across the chest to 
relax the muscles acting upon the shoulder. The displaced 
bone may be retained in place by dressings, which will keep 
the shoulder outward and upward by affording support to 
the arm as Velpeau's bandage. 

Reduction of the forward dislocation is obtained by an 
assistant wiio flexes the arm, and, having drawn it to the 
side of the body, forces it upward, outward, and backward, 
the surgeon meanwhile taking hold of the clavicle, dis- 
lodges it from its position beneath the coracoid process, and 
returns it to its place. 

In view of the difficulties encountered in securing satis- 
factory results after sterno-clavicular and acromio-clavicular 
dislocations by the dressings employed, the late Prof. Gross 
suggested the introduction subcutaneously of silver wire 



348 DISLOCATIONS. 

sutures, for the purpose of uniting the articular extremities, 
permitting them to remain, if not permanently, until firm 
reunion is established. Successful cases have been reported 
in which this plan of treatment has been adopted. 

A number of instances of double dislocation of the clavicle 
have been reported, the result of falls upon the upper and 
back part of the shoulders. Reduction may be effected by 
drawing the shoulders back and pressing the luxated ends 
into position with the fingers. Compresses should be placed 
over the affected articulations and held by posterior figure- 
of-8 and spica bandages of the shoulders. Desault's or 
Velpeau's bandages may be also employed. 

Scapula Systematic writers describe the displacement 

arising from the separation or elongation of the fibres of the 
latissimus dorsi muscle at their point of attachment to the 
inferior angle of the scapula as dislocation of the scapula. 
As no articulation exists at this point, it seems scarcely 
proper to classify it with luxations of this bone. The dis- 
placement occurs most frequently in girls and boys of feeble 
constitution. The angle being freed from its attachment, 
rides over the border of the muscles and forms a marked 
prominence in the dorsal region. Detachment of the mus- 
cular fibres may result from violence, as in a fall or by 
a blow over the part. Efforts should be made by manipu- 
lation to replace the angle beneath the muscle, and then to 
secure it by a compress and broad bandage carried around 
the chest, the arm being supported in the Velpeau position. 

Where the displacement occurs in anaemic children, 
tonics should be administered, and measures should be adopt- 
ed to improve the general health ; a broad bandage should 
be worn about the chest, or suitable braces to throw the 
shoulders back. 



dislocations. 349 

Humerus — Shoulder-Joint — Enarthrodial or 

Ball and Sockkt Articulation Tlie bones entering 

into the formation of tliis joint are the scapula, which 
receives the laro-e orlobidar head of the humerus into the 
shallow glenoid cavity occupying its head. The ligaments 
of the joint are the capsular, a large, loose fibrous mem- 
brane which entirely envelops the articulation, the coraco- 
humeral, a reinforcing ligament, a broad band extending 
from the coracoid process across the capsular ligament to 
the greater tuberosity, and the glenoid, a fibrous band 
attached around the margin of the glenoid cavity to 
deepen it. 

The shallow glenoid fossa, with the globular head of the 
humerus, forming a large articulating surface, inclosed in 
the ample capsular ligament, permits extensive movements 
in this joint — movement in the forward and backward 
direction, abduction, adduction, circumduction, and rotation. 
The construction of the joint, while it allows so much free- 
dom in movement, exposes it to the ready occurrence of 
dislocation, and as a result, this accident affects this articula- 
tion more frequently than any other of the body. Luxation 
takes place oftener in males than in females, owing to the 
modes of life of the former. Dislocations of this joint 
rarely occur before fifteen or after sixty years of age. 

Varieties of Dislocation — The various forms of dislocation 
described in connection with the shoulder-joint, may be, 
with propriety, reduced to four. The displacement takes 
place in three directions, and produces the downward, sub- 
glenoid or axillary ; the forward, siibcoracoid, thoracic or 
subclavicular, and the backward, subspinous dislocation. 
In the subglenoid or axillary luxation, the head of the 
humerus is placed in the axilla, below the margin of the 
30 



350 



DISLOCATIONS. 



glenoid cavity (Fig. 166), in the suhcoracoid, it occupies a 
position a little below and to the inner side of the coracoid 
))rocess (Fig. 167) ; in the stih clavicular or thoracic, below 



Fig. 166. 





the clavicle, at the junction of the anterior, with the 
external surface of the chest (Fig. 168) ; in the sub- 
spinous, on the dorsum of the scapula, below the spine 
(Fig. 169). Of the various forms the subcoracoid occurs 
most frequently. Instances of anomalous dislocations have 
been, from time to time, recorded as the supracoracoid, in 
which the head of the humerus has been placed above the 
coracoid process, as in cases reported by Malgaigne and Mr. 
Holmes ; the subscapular, where the bone occupied the sub- 



DISLOCATIONS. 



351 



scapular fossa, in the case described by Dr. Willard Parker. 
The late Professor Gross had in his cabinet a specimen illus- 
trating what may be designated as the supraclavicular 
variety, the displaced head of the bone being "lodged under 



Fior. 1G8. 





cover of, and partly above the clavicle." An extremely rare 
form of luxation has been described by Larrey, from a prepa- 
ration, in which the displaced bone had penetrated the cavity 
of the chest through the third intercostal space. 

In the complete form of dislocation, the head of the bone 
escapes through a rent in the capsular ligament, more or less 
extensive, in accordance with the force applied in producing 
the luxation. The soft structures surrounding the joint are 
also frequently lacerated and contused. In persons suffering 
from constitutional debility or paralysis, the ligamentous and 
muscular structures surrounding the joint maybe so relaxed 
as to permit luxation without laceration of the capsule. 



352 DISLOCATIONS. 

Causes. — Dislocations of the shoulder-joint may be caused 
by external violence or muscular action. External violence 
may be applied directly upon the anterior, superior, or pos- 
terior surface of the articulation, forcing the head of the 
bone backward, doivmvard, ov forward, producing displace- 
ment in these directions. Force applied indirectly, as in 
falls upon the hand or elbow, may produce displacement in 
the same directions, the arm being at the time drawn back- 
ward, extended, or drawn forw^ard. The effect of muscular 
action in causing luxation has been observed in the violent 
and spasmodic contractions occurring in epilectic convul- 
sions ; also in extreme extension of the arm, the head of 
the bone being in a favorable position to be acted upon by 
sudden contraction of the muscles. Professor Gross quotes 
a ease reported by Dr. Garrison, of Illinois, in which luxa- 
tion occurred in a fit of sneezing. 

Symptoms While the usual symptoms of dislocation, 

pain, loss of function, deformity, and immobility characterize 
all luxations of the joint, each have certain symptoms which 
distinguish them. 

In the subglenoid or axillary variety the complete removal 
of the head of the bone from the glenoid cavity and its posi- 
tion in the axilla, renders the acromion process very promi- 
nent, flattens the shoulder, leaves a depression below the 
process, which can be distinctly felt, and increases the 
height of the axillary space. Through the action of the 
deltoid and biceps muscles, the elbow is projected from the 
body and the arm is flexed. The limb is lengthened. Pres- 
sure upon the nerves and bloodvessels of the axilla causes 
numbness in the forearm and hand, and impairment in the 
force of the arterial pulse. The capsular ligament is torn at 
its inferior part, and the displaced bone lies between the long 



DISLOCATIONS. 



353 



head of the triceps and subscapular muscles, in this position 
rendering unduly tense the deltoid, supra-spinatus, and both 
heads of the biceps. The patient is unable to place the 
hand of the injured arm on the sound shoulder. 

The symptoms of the subcoracoid dislocation are similar 
to those of the subglenoid. The position of the head of the 
bone beneath the coracoid process gives prominence to the 
acromion process, and leaves a depression beneath it into 
which the fingers can be placed (Fig. 170). The head of the 

Fig. 170. 




displaced bone can be felt in its abnormal position, and the 
functions of the arm are markedly impaired. The arm is 
projected backward beyond the middle line of the side of the 
body, the elbow abducted and the forearm flexed on the arm. 
The patient cannot grasp the shoulder of the sound side 
with the hand of the luxated arm. Tlie limb is but little 
increased in length, if at all, shortening being sometimes 
present. The vessels and nerves of the axillary space some- 
times escape pressure, or, at least, less compression is exerted 

30* 



354 DISLOCATIONS. 

upon them than in the subglenoid dislocation. As a rule, 
the compression is very great, and the pain and numbness 
in the arm and fingers are very marked. 

In the subclavicular or thoracic luxation the head of the 
humerus rests upon the anterior lateral surface of the chest, 
between the second and third ribs, and beneath the pecto- 
ralis major and minor muscles. The symptoms are the same 
as those of the subcoracoid variety increased somewhat in 
degree. The great displacement forward of the bone renders 
the deltoid muscle very tense, and gives marked prominence 
to the acromion process. The elbow is projected to a greater 
distance from the side of the body, and is directed further 
backward. Severe compression may be made upon the 
vasculo-nervous cord of the axilla, and, as a result, the pain 
may be very great. Tiie fixed position of the limb produces 
great impairment of function. The head of the bone may 
be seen and felt in its position beneath the lower border of 
the clavicle. The arm in this variety of dislocation is 
shortened. 

The symptoms of the subspinous form of dislocation are 
very characteristic. The displacement backward of the 
head of the bone stretches the clavicular fibres of the deltoid, 
and gives decided prominence to the acromion and coracoid 
processes. The bone is placed in its abnormal position, 
upon the neck of tlie scapula, beneath the border and inferior 
surface of the spine, just behind the angle of the acromion 
process. The limb is advanced beyond the line of the 
body, and crosses the chest in an oblique direction ; it is 
much shortened, and the forearm is rotated inwards, placing 
the hand in a state of pronation. The arm is fixed in its 
abnormal position, and any attempt to move it subjects the 
patient to pain. In this variety the patient can place the 



DISLOCATIONS. 355 

hand of the injured limb on the opposite shoulder, a move- 
ment which cannot be accomplished in any of the three 
forms of dislocation above described. The head of the 
bone can be felt beneath the spine of the scapula. The rent 
in the capsular ligament is usually very extensive, and the 
muscles are lacerated and contused, producing ecchymosis 
and swelling. 

It will be observed that the prominent symptoms of the 
various forms of dislocation of the shoulder-joint relate to 
the configuration of the shoulder, affected as it is by the 
different displacements of the humerus, the position of the 
arm and elbow with regard to the body, the function of tiie 
limb, especially as far as relates to the ability of the patient 
to place the hand upon the opposite shoulder, and compres- 
sion of the vessels and nerves by the displaced bone. 

Diagnosis In making the diagnosis in dislocations of 

the shoulder-joint, it is necessary to distinguish the various 
forms, one from the other, and also from certain conditions 
which simulate them. A careful study of the characteristic 
features of each dislocation will enable the surgeon to recog- 
nize them in his examination of the part. They may be 
tabulated as follows : — 



356 



DISLOCATIONS. 



Subglenoid. 

Shoulder, very much 
flattened, 

Acromioa process 
markedly promiuent. 



Depressiou indicating 
position of glenoid fossa 
very distinct. 

Elbow projected from 
side in the line of axis of 
body. 



Functions greatly im- 
paired. 

Futient unable to place 
hand of dislocated arm 
on opposite shoulder. 

Limb lengthened, usu- 
ally flexed, and forearm 
supinated. 

Displaced head of hu- 
merus felt in the axilla. 

Pain and numbness in 
arm and fingers due to 
compression of axillary 
nerves. 



1. subcoracoid. 
2 Subclavicular. 
Slightly. 

Very much more pro- 
minent in subclavicular 
than in subcoracoid or 
other forms. 

Posterior portion dis- 
tinct. 

Projected from side of 
body and directed back- 
ward, more in subclavi- 
cular than in subcora- 
coid variety. 

Impairment of function 
greater in subclavicular 
than in subcoracoid form. 

The same disability ex- 
ists in these varieties of 
dislocation. 

Limb shortened, twist- 
ed and forearm partially 
flexed. 

Displaced head of hu- 
merus felt in axilla 
higher up and anteriorly. 

Increased pain and 
numbness in arm and fin- 
gers, due to compression 
of axillary nerves. 



Subspinous. 



Slightly. 
Prominent. 



Anterior portion dis- 
tinct. 

In contact with body, 
directed forward beyond 
line of axis of body, rest- 
ing obliquely across tbe 
chest. 

Great impairment of 
function. 

Patient can place hand 
of injured limb on sound 
shoulder. 

Limb much shortened, 
forearm flexed and pi"o- 
nated. 

Axilla free ; displaced 
head of humerus felt be- 
neath spine of scapula. 

No compression of ax- 
illary nerves, and ab- 
sence of pain and numb- 
ness in arm and fingers ; 
pain in shoulder. 



The injuries, the symptoms of which may simulate dislo- 
cation, and which are to be distinguished from it, are contu- 
sions and fractures involving the upper extremity of the 
humerus, the neck of the scapula, or the acromion process. 
In these cases it is essential that the patient should be ex- 
amined under the influence of an anaesthetic. The free and 
unrestricted movements of the limb will distinguish contu- 
sions, Avhile the presence of mobility, crepitus, and easy 



DISLOCATIONS. 3i)7 

removal of the displacement and its prompt recurrence on 
withdrawal of the support, will enable tlie surgeon to recog- 
nize the existence of fracture. In all forms of shoulder- 
joint dislocations, unless the swelling is very great, the head 
of the humerus can be felt in its abnormal situation ; if it is 
grasped, and the arm rotated, the hand of the surgeon will 
readily recognize the movement. 

Prognosis. — In recent and uncomplicated dislocations of 
the shoulder-joint the prognosis is iavorable, the reduction 
being easily effected, and restoration of the functions of tiie 
joint being re-established, as a rule, in a short time. In 
some instances a stiffness of the joint, with imi)aired function, 
ensues, which requires some time to fully remove. Atrophy 
of the deltoid muscle occasionally occurs as a result of the 
injury inflicted upon the parts at the time of the accident. 
Dislocation of the shoulder-joint may be complicated by 
fracture of the humerus, neck of the scapula, or acromion 
process. In these cases reduction may be very difficult to 
accomplish and the functions of the limb greatly impaired. 
In old and neglected dislocations the prognosis is very un- 
favorable, owing to the difficulties and dangers which attend 
efforts at their reduction. 

Treatment. — Tiie reduction in shoulder-joint dislocations 
may be conducted by two methods, manipulation and exten- 
sion and counter-extension. 

By manipulation^ the injured limb is moved in such di- 
rections as to overcome the tension of the muscles, which, by 
their contraction, hold the bone in its displaced position and 
prevent its return to the articulating cavity. In employing 
manipulation it is essential that the surgeon should first 
carefully examine the parts and ascertain which muscles are 
involved. Having determined this point, the limb should 



358 



DISLOCATIONS. 



be placed in the position which will cause their relaxation 
and release the bone, wiiile their subsequent individual or 
combined normal action will assist in restoring it to its place. 

In the various forms of shoulder-joint luxations, the differ- 
ent muscles, which act upon the upper extremity of the 
humerus, are involved in accordance with the character of 
the displacement. 

In the downward dislocation, subglenoid, the deltoid and 
supra-spinatus muscles are rendered abnormally tense, and 
fix the head of the bone in its displaced position against 
the lower border of the glenoid fossa. The lonoj tendon of 
the biceps muscle is, as can be readily seen on examination 

Fig. 171. 




of the articulation, abnormally stretched in all forms of 
scapulo-humeral dislocations. In effecting reduction by 
manipulation in this variety, it is necessary to relax the 
tendon of the biceps, the deltoid, and supra-spinatus, by 



DISLOCATIONS. 359 

flexing tlie forearm and elevating the limb to a position 
along the side of tiie head and then supinating the forearm. 
In this position the head of the humerus can be felt in tlie 
axilla, and should be supported by the fingers of the surgeon, 
the thumb resting on the top of the shoulder. (Fig. 171.) 
The limb should now be depressed to the side of the body, 
the head of the bone being lifted into the socket as the arm 
is brought to a right angle with tlie chest. 

In the forward dislocation, subcoracoid and subclavicular, 
the infraspinatus and teres minor muscles are concerned 
witli the long tendon of the biceps^ the deltoid, and supra- 
spinntus in holding the head of the bone in its abnormal 
situation. The manipulation necessary to secure reduction 
is the same as that practised in the subglenoid variety with 
the addition of external rotation after elevation of the arm, 
in order to relax the supra- and infra-spinati and teres minor 
muscles. 

The posterior dislocation, subspinous, places upon the 
stretch the clavicular fibres of the deltoid, the supraspina- 
ius, the teres major, pectoralis major, and subscapularis 
muscles. The relaxation of these muscles is accomplished, 
and reduction is effected, by elevating the limb to its fullest 
extent, rotating it inward to relieve the tension of the sub- 
scapularis, and pushing the head of the bone forward into 
the glenoid cavity as the arm is carried down to the side of 
the body. 

Prof. H. PI. Smith introduced, some years since, the fol- 
lowing method of reduction by manipulation. Forward and 
backward displacements were converted into the downward 
or subglenoid form as a preliminary step. The forward being 
changed to the downward luxation by simply elevating the 
elbow and carrying it to the head of the patient, the arm 



360 



DISLOCATIONS. 



being kept in the line of the body. The backward disloca- 
tion was converted into the downward by elevating the elbow 
and carrying it forwards. The head of the bone being in 
the axilla, the following manipulations were executed to 
return it to the socket : First, elevation of the elbow and 
arm to the highest point, and flexion of forearm at right 
angles with the arm to relax supraspinatus muscle. Second, 
using the forearm as a lever, rotation of the head of the 
bone upward and forward, as far as possible, is made, to 
relax the infraspinatus, the palm of the hand being directed 
upward ; depression of the elbow to the side, carrying it 
toward the body, and keeping the forearm so that the palm 
is still directed upward. Lastly, quick and gentle rotation 
of the head of the humerus upward and outward by carrying 
the palm downward and across the patient's body. 

Reduction by extension and counter -extension may be ac- 
complished by various methods. A very effective and simple 

Fig. 172. 




DISLOCATIONS. 3G1 

plan is tliat known as Sir Astley Cooper's, in which extension 
is made by tlie surgeon grasping the arm of the patient, 
counter-extension being made by placing the foot in the 
axilla. The patient is placed in the recumbent position upon 
a low bed, table, or on the floor. Extending bands, made 
with a towel or sheet, are fastened to the arm above the 
elbow and the limb flexed at a right angle. A towel is 
placed in tiie axilla to protect it, and the surgeon, sitting 
upon the bed with one foot upon the floor, places the other, 
divested of the shoe, against the compress in the axilla. 
Steady and continuous traction is now made by means of 
the extending bands, which, if necessary, may be passed 
around the shoulders of the surgeon, the limb being gradu- 
ally carried forward across the body. (Fig. 172.) 

Reduction may be also effected by placing the knee in the 
axilla, the patient beinfr seated in a chair and the foot of the 
surgeon resting upon it or a stool placed near by. The arm is 
grasped with one hand, while the other is placed on the top 
of the shoulder, and the limb is bent over the knee, the head 
of the bone being, by this movement, raised into its socket. 
(Fig. 173.) 

Another plan in which reduction is effected by extension 
and counter-extension is that usually described as La Mothe's. 
According to this method the patient is placed in the re- 
cumbent position upon a table, and the surgeon, standing at 
his head, grasps the arm above the elbow with one hand, 
while the other is placed upon the top of the shoulder, so as 
to make counter-extension. (Fig. 174.) Extension being 
made, the bone will usually return to its place. Increased 
power may be gained by putting the foot on the top of the 
shoulder, and assistance will be rendered by rotating the 
limb and carrying it from the body while extension is made. 
31 



DISLOCATIONS. 

Fi?. 173. 




Fig- 174. 




DISLOCATIONS 3(53 

Tlie (lis[)laced bone may be reduced by making extension 
and counter-extension, by placing tlie foot on the posterior 
fold of the axilla, so as to steady tlie scapula, and making 
traction with the arm at right angles to the body. The effort 
is completed by bringing the arm to the side of the body so 
as to direct the bone into the articulating cavity. 

Tiiis plan of extension is somewhat modified in the method 
of Dr. Logan, of New Orleans, the surgeon gras[)ing the 
shoulder between the feet and traction being made with the 
arm at right angles to the body. In executing this raa- 
n-cuvre, the heel of one foot is placed in the axilla, against the 
ribs, so as to press somewhat obliquely, and the base of the 
great toe of the other foot rests against the acromion process. 
In both of the methods, in which the extension is made at 
right angles to the body, the movement is best accomplished 
when the patient is in the recumbent position on the floor. 

The method of Dr. Nathan Smith in making extension 
and counter-extension with the arm at riglit angles to the 
body is seen in Fig. 175. The sound arm being carried 
from the body at right angles, a counter-extending band, 
made from a folded sheet, is placed around the chest, the 
ends passing in front and behind the chest and arm, and is 
secured at the wrist by a circular band. The extending band 
is fastened by figure-of 8 turns to the wrist and hand of the 
injured arm, while a third band passing over the top of the 
shoulder is secured to the chair. Tiie surgeon, with the foot 
upon the chair, places the knee in the axilla and as exten- 
sion and counter-extension are made, lifts the bone into 
place. 

If reduction cannot be obtained by the methods above de- 
scribed an effort may be made to accomplish it by means of 
the compound pulleys. They should be employed with 



3U 



DISLOCATIONS. 

Fig. 175. 




great care lest serious injury be inflicted upon the structures 
of the joint. They may be applied in the manner repre- 
sented in Fig. 176, the patient being seated in a chair, and 
counter-extension being made by a band with an opening in 
it through which the injured arm is passed. 

It is desirable, in all cases of luxation of this joint, to 
make efforts at reduction, while the patient is under the in- 
fluence of an anaesthetic, so as to secure complete relaxation 



DISLOCATION'S. 



365 



of the muscles involved in the dislocation and avoid resist- 
ance on the part of the patient. 



Fiff. 176. 




After reduction, the arm should be supported in the Vel- 
peau or Desault bandage for a period of ten days or two weeks 
and then for a similar period carried in a sling. Rigidity of 
the parts may be removed by frictions with stimulating lini- 
ments and careful passive movements. In obstinate cases the 
rigid tendons and muscles may be divided subcutaneously. 
If much contusion has been received at the time of the ac- 
cident, the pain and swelling may be relieved by enveloping 
the parts in compresses wet in a solution of laudanum and 
lead-water. 

Paralysis and atrophy of the deltoid muscle may be treated 
31* 



3G6 DISLOCATIONS. 

by the application of electricity, the cold douche, frictions, 
and counter-irritation, vesication being sometimes of great 
service. 

The treatment in cases of dislocation complicated with 
fracture of the humerus consists in the application of tempo- 
rary dressings for the fracture, in order that the limb may 
be used in the manipulations necessary to effect reduction. 
After reduction of the luxation, permanent fracture dress- 
ings should be applied. When the dislocation is accompa- 
nied by fracture of the anatomical neck of the humerus, 
efforts may be made to restore the displaced bone by pres- 
sure — these are usually unavailing. Luxation, with frac- 
ture of the neck of the scapula, is attended with great em- 
barrassment in effecting reduction, owing to the mobility of the 
head of the scapula on which the glenoid fossa is placed and 
the difficulty of rendering it immovable. Fracture of the 
acromion process of the scapula does not complicate disloca- 
tion very seriously. 

Compound dislocations of the shoulder-joint are rare in 
occurrence. The displaced bone should be returned, if 
uninjured, and tlie injury treated as directed in the general 
discussion of compound dislocations on page 314. 

Emphysema, suddenly developed in connection with dis- 
location, sometimes occurs and is due to wounding of the 
chest by the displaced bone. The swelling, beginning beneath 
the pectoralis major muscle, spreads rapidly to the axilla and 
surrounding parts. Compression, firmly made with bandages, 
applied to the arm and chest, is usually sufficient to control 
the condition. 

Rupture or laceration of the axillary artery or vein is an 
accident which sometimes attends dislocation of the shoulder- 
joint. In case of complete rupture, producing extensive in- 



DISLOCATIONS. 3G7 

filtration of blood into the tissues, prompt ligation of both 
ends of the torn artery is the proper treatment. Where 
laceration of the inner coats of the artery occur forming dif- 
fused aneurism, ligation of the subclavian artery should be 
performed. In one case, reported by Berard, in which pul- 
sation of the radical artery ceased after subcoracoid lux- 
ation, gangrene attacked several of the fingers and death 
subsequently occurred. Laceration of the axillary vein should 
be treated by pressure with compresses and a roller firmly 
applied. 

Double dislocations of the shoulder-joint, which occur 
rarely, are the result of falls, the patient extending both hands 
to avoid injury. The displacement may be the same in both 
joints or may vary. Fracture of the scapula, clavicle, or 
humerus frequently accompanies this form of luxation. The 
late Prof. Gross observed two cases of simultaneous disloca- 
tion, one occurring in his own practice, both having taken 
place during an attack of epileptic convulsions. Dr. Nathan 
Smith reported a case occurring in an attack of puerperal 
convulsions. The treatment of double luxations is to be con- 
ducted in the same manner as that in single displacements. 

Old Dislocations — The pathological changes which take 
place in old unreduced dislocations have been freely discus- 
sed on page 317. The question of interference in these cases 
is a very important one, and requires serious consideration 
on the part of the surgeon. "While there are a number of 
instances on record in which successful efforts at reduction 
have been made at the expiration of several months, there 
are also records of cases in which very serious accidents and 
fatal results have followed efforts at reduction at much less 
period of time, and hence there can be no general rule laid 
down for guidance in these cases. The conditions which 



308 DISLOCATIONS. 

would call for interference on the part of the surgeon relate 
to the character of the new articulation formed, as far as 
usefulness, of the limb is concerned, and the existence of 
pain. If it is found upon examination that the movement 
of the limb is free, and not restricted to any great extent, it 
may be inferred that such changes in the surrounding struc- 
tures have occurred, in the formation of a new joint, as to 
make it hazardous to interfere. The same may be said if 
there is the history of severe inflammation following the re- 
ceipt of the injury as tlie result of which the structures are 
consolidated by plastic deposits. If great pain is present, as 
the result of pressure by the displaced bone upon the axillary 
nerves, then an attempt at reduction is justifiable if the con- 
ditions of the parts are favorable. Otherwise, the operation 
for the formation of a false joint by subcutaneous section 
of the neck of the humerus, performed by the author, with 
prompt relief, in a case of unreduced subcoracoid dislocation 
of the shoulder of fourteen months' duration, should be made. 
This case was fully reported in a paper read before the 
College of Physicians of Philadelphia, and published in 
volume third, 1877, of its Transactions. Excision of the 
head of the bone may be performed if all other means of re- 
lief fail. If attempts at reduction are to be undertaken, the 
preliminary treatment should be carried out as directed in 
the discussion of the subject of old dislocations on page 317. 
The safest plan of extension to be practised is that made 
with the arm at right angles to the body, or timt in which 
the arm is held alongside of the body. The great tension to 
which the arteries, veins, and nerves, matted together by in- 
flammatory products, are subjected, in the method of exten- 
sion by elevation of the arm along the side of the head 
renders this plan very dangerous. In the attempt at reduc- 



DISLOCATIONS. 369 

tion of a dislocation of six weeks' standing by this plan, 
Prof. Agnew ruptured the axillary vein in a woman sixty 
years old, who recovered under the use of sorbefacient lotions 
and firm bandaging. Dr. Willard, of this city, has col- 
lected and analyzed nineteen cases of rupture of the axillary 
artery following efforts at reduction in old dislocations of the 
shoulder-joint. Of these, twelve died, six recovered, and 
in one the result was unknown. In three of these cases the 
axillary artery was ligated without benefit ; in four the sub- 
clavian, with two successful results. Rupture of both artery 
and vein occurred in three cases, two of which terminated 
fatally — the result in the other was not stated. As stated 
above, ligation of the artery should be performed in all cases 
of rupture. Contusion, rather than laceration, of the axillary 
7ierves is liable to follow efforts at reduction in old disloca- 
tions of this joint. Impaired function, with pain and swell- 
ing of the limb, occurs. When rupture of any of the 
principal nerves takes place, paralysis of the parts supplied 
by the nerve follows the accident. In these cases, the arm 
should be confined in Desault's or Velpeau's dressing until 
repair of the injury has occurred, massage and friction being 
then instituted to assist in restoring the impaired function. 

Fractures of the humerus occurring in connection with 
attempts at reduction should be treated upon general prin- 
ciples. Mr. Tee van, of London, has reported a case of 
fracture of the ribs following pressure in the axilla during 
efforts at reduction. 

The inflammation which follows the separation of the ad- 
hesions in old dislocations is sometimes of a very severe 
character, and may result in the formation of a diffused ab- 
scess, endangering the life of the patient. 



370 DISLOCATIONS. 

Cases have been reported in which death has followed as 
the result of shock. 

Considering the dangers which attend efforts at reduction 
in old dislocations of the shoulder-joint, the following propo- 
sitions may be stated for guidance in their employment. 

1. In view of the varying conditions which attend old 
luxations of the shoulder-joint in different individuals, the 
rule applied by Sir Astley Cooper, fixing three months, after 
the receipt of the injury, as the limit beyond which any 
efforts at reduction should be regarded as injudicious, except 
in persons of very lax fibre or advanced age, may be ac- 
cepted as a guide. 

2. Interference should be avoided in those cases in which 
free movements of the limb indicate the formation of a new 
joint, and the establishment of such relations of the sur- 
rounding structures to it by inflammatory action as to ren- 
der manipulative efforts dangerous. 

3. The occurrence of severe inflammation after the re- 
ceipt of the injury, indicaHng, as a result, the consolidation 
of the structures by plastic deposits, and the formation of 
extensive adhesions between the displaced bone and the 
structures, may be accepted as a contra-indication to the 
adoption of efforts at reduction. 

4. Interference should be avoided in those cases in which 
the function of the limb is not very greatly impaired, and in 
which some doubt may exist as to the re-establishment of 
more perfect movements after reduction. In connection 
with this proposition, the question of the risks assumed in 
making the attempts at reduction should be considered. 

0. Interference is justifiable in cases in which there is 
great impairment of function or constant and excessive pain 
due to pressure of the displaced head of the humerus upon 



DISLOCATIONS. 371 

the brachial plexus of nerves. In siicli cases, the formation 
of a false joint, by subcutaneous section through the surgical 
neck of the bone, or excision of the head of the bone, is the 
proper method of treatment to be pursued. 

6. In all cases in which efforts at reduction are under- 
taken, preliminary treatment should be instituted to place 
the patient and the parts in the best condition. The diffi- 
culties and dangers attending the procedure should be 
clearly explained to the patient, in order that the surgeon, 
in the proper performance of his duty, may not be held re- 
sponsible for accidents beyond his control. 

Congenital Dislocations — Instances of congenital disloca- 
tions of the shoulder-joint have been recorded and carefully 
studied by Mr. R. W. Smith in his work on Fractures, Gail- 
lard, as quoted by Malgaigne, Gu^rin, Nelaton, and others. 
Two varieties, the suhcoracoid and subacromial^ have been 
described. Among the symptoms presented in these cases is 
atrophy of the arm, with normal development of the fore- 
arm. The other symptoms are the same as those accom- 
panying ordinary traumatic dislocations. The changes 
present in the articulation in these cases, consequent upon 
defective development, render their treatment usually unsuc- 
cessful. When attempted, it should be conducted according to 
the methods employed in luxations generally. 

Dislocation of the shoulder-joint occurs sometimes as the 
result of traction made upon the arm during parturition. 
Prof. Agnew states " it is not improbable that such may 
have been the origin of some of the cases recorded as con- 
genital dislocations." 

Dislocation of the tendon of the biceps muscle is reported 
as having occurred independent of luxation of the humerus. 
In connection with dislocation of the humerus it may be 



372 DISLOCATIONS. 

wrenched from its position in the bicipital groove, lacerated 
or completely ruptured. As an independent lesion the 
symptoms which attend it are very obscure. The absence of 
the displacement of the head of the humerus from the glenoid 
cavity, with more or less prominence of the head of the 
humerus, pain in the region of the bicipital groove, and in- 
ability to flex the forearm upon the arm, may be regarded 
as symptoms of the lesion. In certain cases it may be pos- 
sible to feel the displaced tendon. The treatment consists 
in flexing the arm at right angles and making efforts to 
press tlie tendon back into its groove with the fingers. The 
arm placed at a right angle should be carried in a sling or 
supported in the Desault dressing. Local applications 
should be made to combat the inflammation which generally 
supervenes, and which may produce anchylosis of the shoulder- 
joint. 

Radius and Ulna — Elbow-Joint — Ginglymoid Ar- 
ticulation The bones entering into the formation of this 

joint are the humerus, radius, and ulna, firmly united by 
the anterior, posterior, external and internal lateral liga- 
ments, together forming a loose capsule which envelops the 
articulation and incloses an extensive synovial membrane. 
Being a true ginglymoid or hinge-joint, its movements are 
limited to flexion and extension, through the articulation of 
the trochlear surface of the humerus with the greater sisr- 
moid cavity of the ulna. The articulation of the cup-shaped 
depression on the head of the radius with the radial tuber- 
osity of the humerus permits the movement of rotation of 
the radius on the ulna. The radius, therefore, has a double 
movement of gliding in flexion and extension of the arm 
and rotation in the movement of supination and pronation 
of the forearm. 



DISLOCATIONS. 373 

The muscles in rehition with the articulation are the 
biceps and bracliialis anticus in front, the triceps and an- 
coneus behind, the supinator longus and brevis, with the 
common tendon of origin of the extensor muscles of the 
forearm externally, and the common tendon of origin of the 
flexor muscles internally. Those which are chiefly concerned 
in the displacements, which occur in dislocations of the joint, 
are the triceps, biceps, brachialis anticus, and supinators. 
The brachial artery and median nerve occupy important re- 
lations in front of the joint, with the musculo-spiral nerve 
externally and the ulnar in the groove upon the back of the 
inner condyle of the humerus. 

Dislocations of the elbow-joint occur most frequently in 
early life. Hospital statistics showing that the majority take 
place under fifteen years of age, the average, in a number, 
being about twenty years. The accident is rare after forty- 
five years — as with luxations of the shoulder-joint it occurs 
more frequently in males than in females. 

Dislocations of the articulation may be divided into those 
of the humerus, radius and ulna^ of the humerus and ulna, 
and of the humerus and both radius and ulna, commonly 
described as dislocation of the elbow-joint. 

Humerus, Radius and Ulnar — Superior Radio- 
ulnar Articulation — Lateral Ginglymoid — This 
joint is formed by the inner side of the circumference of the 
head of the radius, and lesser sigmoid cavity of the ulna in 
wliich it rotates. The radius is held in place by the orbicular 
ligament which surrounds its neck, and the joint is lined by 
an expansion of the synovial membrane of the elbow-joint. 
The movement of the articulation is confined to rotation of 
the head of the radius, within the orbicular ligament. The 
proximity of tliis articulation to that of the elbow and the 
32 



374 DISLOCATIONS. 

relation held by the radius to both, makes it important that 
their construction and movements should be studied in con- 
junction. The explanation of the great difficulties which 
attend reduction in dislocations of the elbow-joint, after the 
lapse of a short period of time, may be found, I believe, in 
the relation assumed by the structures entering into the 
formation of both articulations, on account of the indepen- 
dent movement of the radius. 

In the complete forms of dislocation of the humerus, radius, 
and ulna, the anterior, external lateral, and posterior liga- 
ments, with the orbicular, are torn and the radius is separated 
from the lesser sigmoid cavity of the ulna and from the radial 
head of the humerus, and placed m front of, behind, or ex- 
ternal to the external condyle of the humerus, forming a 
dislocation yb^'tt'arc?, backward, and outward. 

Causes The cause of radio -ulnar -linmeral dislocations is 

external violence, applied either directly or indirectly. It 
is applied most frequently in the indirect manner, as in falls 
upon the hand, the forearm being at the time in a state of 
extreme pronation. 

In the /or^^wrc? luxation the displacement may occur as 
the result of blows or kicks upon the posterior surface of the 
upper extremity of the radius, of severe wrenches or twists 
of the forearm, or of falls upon the hand. 

Bachivard dislocation may be produced by direct force 
applied to the anterior surface of the head of the radius, by 
extreme forcible pronation of the hand, or by falls upon the 
hand, the forearm being in a state of pronation and carried 
away from the body. Fracture of the condyle of the humerus 
frequently accompanies this form of luxation. 

The outward dislocation, in the complete variety, is the 
result of extreme violence indirectly applied, through falls 



DISLOCATIONS. 375 

upon the band. In order to place the head of the radius 
upon the external surface of the condyle, the ulna retaining 
its position, a laceration of the oblique and interosseous liga- 
ments must occur. The violence necessary to accomplish 
this would be liable to produce, at the same time, fracture 
of the ulna or humerus and, as well, inflict great injury upon 
the soft structures. 

Si/nipfoms. — The symptoms of tlie various forms of dis- 
placement are usually characteristic, the different positions 
assumed by the head of the radius giving a distinctive char- 
acter to the deformity. The pain is caused rather by the 
injury inflicted upon the soft structures at the time of the 
accident, than by the implication of any of the large nerves 
in relation with the joint or the muscular tension due to the 
displacement. The function of the joint is abridged, not 
totally lost in any form. 

In the foru'a?'d dislocation, the position of the head of the 
bone upon the anterior surface of the condyle (Fig. 177) 

Fie:. 177. 




shortens the radial side and rotates it outward. Flexion of 
the forearm at a right angle is prevented by the brachialis 
muscle which holds the radius in contact with the anterior 



37r> DISLOCATIONS. 

surface of the humerus, thus interfering with its further dis- 
placement upward. Extension cannot be completely obtained 
owing to the position of the head of the radius, which can 
be felt rotating beneath the finger, when efforts at supina- 
tion and pronation are made. The biceps and supinator 
brevis muscles are relaxed and the forearm is usually parti- 
ally flexed, and in a position of slight pronation or midway 
between supination and pronation. The lesser sigmoid cav- 
ity of the ulna, made vacant by the displacement of the 
bone, can be felt as a depression below the external condyle 
of the humerus. 

In the hacJcward luxation, the loss of function is very 
marked, the limb being semi-flexed, and in a fixed state of 
pronation. The movements of extension, flexion, and supi- 
nation cannot be executed without the employment of much 
force. The biceps muscle is tense, its tendon being felt be- 
neath the skin. The depression caused by the unoccupied 

Fig. 178. 




sigmoid cavity cannot usually be distinctly outlined, owing 
to the position of the bone. The displaced head of the ra- 
dius can be felt in its fixed position on the posterior surface 
of the condyle (Fig. 178), by the side of the olecranon pro- 
cess. The fingers are usually somewhat bent. 



DISLOCATIONS. 377 

The outward luxation is characterized, in the complete 
variety, by marked deformity, caused by the position of the 
head of the radius upon the outer surface of the external 
condyle. The function of the limb is very much impaired, 
flexion and extension being restricted, and the movement of 
supination abolished or executed with great difficulty. The 
arm is placed midway between pronation and supination, 
with marked prominence of the radial border of the forearm. 

Diagnosis The symptoms in the different varieties of 

dislocation of the humerus and radius are sufficiently dis- 
tinctive to render the diagnosis easy after careful examina- 
tion and study. The prominence afforded by the displaced 
bone, in the different positions occupied, will enable the sur- 
geon to distinguish it. If the movements of pronation and 
supination are executed, the rotation of the head can be 
readily felt. 

■^ Prognosis The difficulty of effecting reduction and reten- 
tion in the forward dislocation makes the prognosis in this 
variety doubtful. In unreduced luxations the functions of 
the joint are not materially impaired, the movements of ex- 
tension, pronation, and supination being well performed 
while that of flexion gradually improves. 

In the backward and outward luxations the prognosis may 
be regarded as favorable. 

Treatment Reduction may be effected in the forward 

luxation by flexing the arm to increase the relaxation of the 
biceps muscle and then making extension from the hand, 
counter-extension being accomplished by an assistant who 
grasps the arm. Whilst extension is being made, the sur- 
geon should press the head of the radius downward and out- 
ward, the forearm being placed at the same time in a state 
of supination. 

32* 



378 DISLOCATIONS. 

The hachward and outward dislocation may be reduced 
by the same method. After reduction, the arm should be 
placed, in iki^ forward variety, at a right angle, and held in 
this position by either an anterior or posterior angular splint. 
A compress may be placed over the joint to assist in pre- 
venting displacement, and a bandage applied to hold the 
compress and splint in position. The dressings should not 
be disturbed under ten days or two weeks' time. Support 
should be given to the joint for two months, as that time is 
required for complete repair. The splint applied in the 
hachward displacement should be at an obtuse angle or near- 
ly straight, so as to prevent recurrence of the luxation. 

When the reparative process has progressed sufficiently, at 
the expiration usually of ten days or two weeks, passive mo- 
tion should be carefully instituted to avert anchylosis. 

Great difficulty frequently occurs in effiicting reduction in 
these dislocations, and after the lapse of a few days it some- 
times is found impossible to accomplish replacement of the 
bone, especially in the forward variety. Careful attention 
should be given to the application of tiie retentive dressings 
as there exists a great tendency to the recurrence of dis- 
placement. 

In persons of ansemic condition, in whom there is a relaxed 
state of the nniscular and ligamentous tissues, subluxation 
at the superior radio-ulnar articulation frequently exists. 
It occurs in children of a strumous habit and in females 
oftener than in males. Tiie functions of the limb are not 
seriously affected. Tlie treatment consists in general con- 
stitutional remedies to restore tone to the system and the 
local application of counter-irritants, small blisters frequently 
repeated, being of great service. 

HuMEKUS AND Ulna. — The separation of the ulna from 



DISLOCATIONS. 



379 



the hiinierus occurs very infrequently. The disphicenieut 
is usually backivard, the coronoid process resting in the ole- 
cranon fossa of the humerus or behind the internal condyle 
(Fig. 179). In this displacement the orbicular, as well as 
the oblique ligament and interosseous membrane will be 
ruptured. In the complete variety the coronoid process is 
usually fractured. 

Fisr. 179. 




Causes The dislocation is the result of severe violence 

applied indirectly, as in falls upon the inner and upper part 
of the hand, the force being transmitted in the line of the 
ulna while the arm is in such position of flexion as to favor 
the separation of the bone from the trochlear surface of the 
humerus. 

Symptoms — The symptoms are very characteristic, the 
forearm and hand being flexed and the limbs presenting a 
twisted appearance. The function of the arm is very much 
impaired, both flexion and extension, especially the latter, 
being restricted and painful. The olecranon process can be 
distinctly felt in its abnormal position. If fracture of the 
coronoid process has occurred, the displacement backward 
and upward of the olecranon process will be greater and as 
a result the deformity will be increased. The head of the 
radius is usually slightly displaced from its articulating surface. 

Diagnosis The prominence formed by the displaced 



380 



DISLOCATION: 



olecranon process is so distinctive of this dislocation that 
little or no difficulty should be experienced in arriving at a 
correct conclusion with regard to the nature of the injury. 
Associated with the prominent projection of the process, is 
the twisted appearance of the limb which is characteristic of 
the luxation. 

Prognosis. — The prognosis in dislocation of the ulna is 
favorable, both with regard to reduction and the restoration 
of the function of the limb. 

Treatment — The return of the displaced bone to its place 
may be readily accomplished by placing the knee in the 
bend of the elbow and making extension by grasping the 
hand and wrist or forearm. If difficulty is experienced, 
pressure may be made on the process to assist in effiicting 
reduction. The arm should be secured to an anterior or 
posterior angular splint, of slight angle, by bandages, and 
maintained in this position for two weeks. If fracture of 
the coronoid process is associated with the dislocation, the 
arm should be placed in a posterior rectangular case, made 
of felt or tin. and a compress placed over the position of the 
coronoid process, the whole being held in place by a roller. 

Radius and Ulxa — Elbo^v Joint The dislocation of 

both bones of the forearm at the elbow-joint is usually desig- 



Fi-. ISO. 




DISLOCATIONS. 



381 



Fig. 181. 



nated dislocation of the elbow. The displiicenient may occur 
in the backward, forivnrd, outward and inward direction. 

In the backward dislocation, both bones of the forearm 
leave the articulating surfaces of the humerus and take a 
position posterior to the lower 
extremity of the bone, the coro- 
noid process of the ulna occupy- 
ing the olecranon fossa and the 
head of the radius resting in 
contact with the posterior sur- 
face of the external condyle. 
(Fig. 180). 

In the forward luxation, 
which, as an uncomplicated 
lesion, is extremely rare, the 
position of the bones of the 
forearm is rever>ed, tliu head 
of the radius being placed in 
front of the external condyle 

and the olecranon process over the coronoid fossa. In the 
incomplete variety, the upper surface of the olecranon pro- 
cess is placed over the coronoid fossa, the radius having no 
point of contact. (Fig. 181.) 

The /«^era/ displacements of the bones of the forearm are, 
as a rule, incomplete, the articulating surfaces being rarely 
entirely separated. 

In the outward dislocation the head of the radius slips 
beyond the border of the external condyle, dragging the ole- 
cranon process with it, but not separating it completely from 
the trochlear surface. (Fig. 182.) 

The olecranon process, in the inward luxation, leaves the 
trochlear surface and embraces the internal condyle, while 




382 



DISLOCATIONS. 



the head of the radius rests in contact with the lower border 
of the trochlear surface. (Fig. 183.) 

Causes The dislocations of the elbow-joint, in the vari- 
ous directions described, are caused by severe violence ap- 

Fiff. 182. 





plied directly or indirectly. The effect of the application of 
direct violence is seen in falls upon the point of the elbow, 
the arm being in a state of extreme flexion ; as the result of 
the impact of force, the. forward variety of displacement may 
be produced. 

Lateral displacements either outward or inward may oc- 
cur also as the result of direct violence, as when the arm is 



DISLOCATIONS. 



383 



caught in the spokes of a wheel in motion, or by a rapidly- 
revolving belt attached to machinery. Falls from a height 
upon the hand, the arm being at the time in a position 
favorable to permit separation of the articulating surfaces of 
the bones of the elbow-joint, may produce the backward dis- 
location. 

Symptoms. — The symptoms in the various forms of dislo- 
cation of the elbow-joint are very prominent. They are 
characterized usually by great pain, increased upon efforts 
at movement, marked deformity and immobility. Loss of 
function is also present, the movements of the limb being 
very much abridged, if not entirely annulled. The position 
of the displaced bones in each variety of dislocation affords a 
distinguishing symptom by which it may be recognized. 

Fiff. 184. 




In the luxation backward the anterior and lateral liga- 
ments are ruptured and the brachialis muscle, with the ten- 



384 DISLOCATIONS. 

don of the biceps, made tense as they pass over the end of 
the humerus. The triceps muscle may be readily grasped 
at its point of insertion into the olecranon process, and it is 
either tense or relaxed, according to the position of the arm, 
whether flexed or extended. (Fig. 180.) Tlie median and 
ulnar nerves may be subjected to pressure between the pos- 
terior and lower surface of the end of the humerus and the 
bones of the forearm. Great swelling usually attends the 
injury and contributes to the deformity, which is usually 
very great. The distance between the wrist and elbow- 
joints is diminished on the anterior surface, and the arm is 
twisted and flexed, the forearm being either in a state of 
slight pronation or in that midway between supination and 
pronation. (Fig. 184.) The function of the arm is much 
impaired, flexion and extension being materially restricted 
and much pain being caused on making attempts to effect 
movement. If the part is examined before much swelling 
has supervened the displaced olecranon process can be read- 
ily felt in its position behind the humerus where it forms a 
marked prominence. A projection somewhat more promi- 
nent, can be outlined on the anterior surface of the forearm, 
caused by the lower extremity of the humerus. 

The comi^lete forivard dislocation is accompanied by rup- 
ture of all of the ligaments of the joint, with more or less 
contusion and laceration of the surrounding soft structures. 
The triceps muscle is rendered unduly tense and in close 
contact with the end of the humerus, while the biceps and 
trachealis anticus are much relaxed. The distance between 
the wrist and elbow-joint is decreased on the posterior sur- 
face, the forearm being slightly flexed. The olecranon 
process and head of the radius can be felt in front of the 
lower end of the humerus — the latter can be distinguished 



DISLOCATION'S. 38o 

by the movement imparted to it on making rotation of the 
forearm. Posteriorily, the end of the humerus with the 
smooth articular surfaces, condyles, and olecranon fossa may 
be outlined. Extension of the forearm can be effected 
without much effort. When the dislocation is incomplete, 
lengthening, instead of shortening, of the forearm is pre- 
sent, with flexion. 

In the incomplete oiitivard lateral dislocation, which is 
the usual form, the head of the radius does not entirely 
separate itself from the articular surface of the humerus. 
The ulna also remains in partial contact with the trochlear 
surface. In the complete variety the radius is carried be- 
yond the external condyle, Avhile the ulna surmounts it. 
As a result of this lateral displacement of the bones of the 
forearm, the elbow is increased remarkably in breadth and 
the muscles taking origin from the external and internal 
condyles are made very tense. The undue tension of the 
pronator radii teres produces forced pronation of the forearm. 
The action of the muscles upon the displaced bones, to- 
gether with their abnormal positions, produce a twisted 
condition of the limb. 

The inward lateral luxation is also characterized by great 
deformity of the iimb, especially noted upon the ulnar side, 
and, as in the outward displacement, there is a great increase 
in the breadth of the articulation. 

The forearm is maintained in a state of supination by the 
action of the supinator brevis and longus muscles, which 
are rendered tense, especially the former. In the complete 
variety of the dislocation the displaced olecranon yn'ocess of 
the ulna may be felt on the inside of the joint, while on the 
outer aspect the external condyle forms a very prominent 
projection. 
33 



386 DISLOCATIONS. 

Diagnosis. — While the symptons accompanying the va- 
rious forms of displacement of the elbow-joint are usually 
well marked and sufficiently distinctive, it requires, in many 
instances, the most careful examination and study to deter- 
mine the exact character of the dislocation. Owing to the 
severe violence required to produce these injuries, contusions 
and lacerations of the soft structures occur, and as a result, 
great swelling rapidly supervenes. This condition interferes 
very much with a satisfactory examination of the parts and 
obscures the symptoms present. Fracture of the humerus 
above the condyles, of the olecranon process of the ulna or 
the neck of the radius may resemble posterior dislocation of 
the bones of the forearm, but can be distinguished from it by 
careful examination and comparison of the symptoms. Frac- 
ture of the humerus is characterized by the following symp- 
toms : Position of the olecranon process normal, on a line with 
the condyles of the humerus ; mobility of arm and forearm, 
flexion, extension, pronation, and supination preserved; crepi- 
tus obtained on bringing the fragmentsin contact and making 
rotation ; no shortening of the forearm ; ei\d of upper fragment, 
forming prominence on anterior surface, rough and flattened ; 
flexion of the arm diminishes prominence of posterior pro- 
jection. In the backward dislocation of the radius and 
ulna the position of the olecranon process is above the line 
of the condyles — the movements of the limb restricted, fore- 
arm fixed, crepitus absent, anterior surface of forearm short- 
ened, lower end of humerus smooth, preserting articular 
surfaces, flexion of arm increases prominenc^^ of posterior 
projection. In fracture of the olecranon process, the de- 
tached portion can be felt in its elevated position, and the 
depression caused by separation of the fragments can be 
easily recognized. In fracture of the neck of the radius, 



DISLOCATIONS. 387 

there is an absence of deformity on the posterior surface of 
the articuhition, and crepitus can be elicited on rotation of 
the bone. 

Prognosis, — The injury inflicted upon the parts at the 
time of the production of the dislocation, as well as the 
great difficulties experienced in effecting reduction in one 
variety, the backward luxation, renders the prognosis doubt- 
ful. In the backward dislocation it is sometimes found im- 
possible to effect reduction at the expiration of so short a 
period as the second or third week. Several instances are 
recorded, however, in which it has been accomplished after 
the lapse of six months. Severe inflammation, suppuration, 
and gangrene have followed long-continued attempts made 
at reduction. In one instance, rupture of the brachial artery 
occurred, necessitating amputation at the elbow-joint to save 
the patient's life. In another case, death followed the acci- 
dent. 

Treatment — Reduction, in the different forms of dislocation 
of tiie elbow, may be effected by extension and counter-exten- 
sion, with the arm in either the flexed or straight position. 

In the backward dislocation, the method of Sir Astley 
Cooper may be employed, which consisted in seating the 
patient in a chair, while the surgeon, standing in front, 
placed the knee in the bend of the elbow, the foot resting 
upon the chair. The surgeon, grasping the forearm, makes 
extension, at the same time bending the elbow round the 
knee and pressing with it upon the inner surface of the joint 
so as to afford counter-extension and leverage. By the lat- 
ter, the coronoid process is lifted out of the olecranon fossa, 
the efforts at extension being usually successful in restoring 
the bones to place. (Fig. 185.) 

This method was modified by the late Prof. Gross, who 



388 



DISLOCATIONS. 



Ficr. 185. 



obtained more power by placing the heel in the bend of the 
elbow, made extension by grasping the forearm, and assisted 

reduction by bending the 
forearm over the chest. 
To afford still greater 
power, bands may be se- 
cured to the forearm and 
then placed over the shoul- 
ders of the surgeon. In 
effecting reduction by this 
plan the patient is placed 
in the recumbent position. 
Reduction has also been 
accomplished by bending 
the arm round a bed-post 
while extension is made. 

Pressure made firmly 
upon the displaced olecra- 
non process by the thumbs 
of the surgeon while ex- 
tension and counter-exten- 
sion is effected by assistants, who grasp the arm and forearm, 
will sometimes aid in obtaining replacement. 

In cases which resist reduction witli the arm in the flexed 
position, the coronoid process may be unlocked from its posi- 
tion in the olecranon fossa by forcibly extending the limb 
beyond the straight line and then accomplishing reduction 
by extension and counter-extension. This plan is very 
effectual in old dislocations. 

If still greater power is required in making extension the 
compound pulleys, which may be fastened to the forearm 
by appropriate bands, may be employed. Counter-extension 




DISLOCATIONS. 389 

IS obtained by bands attached to the arm and secured to the 
bed-post or confiiled to the care of strong assistants. Great 
care should be exercised in making traction lest injury 
be inflicted upon the structures of the joint. The patient 
should be in the recumbent posture and under the influence 
of an antesthetic. 

When all other means ftiil in effecting reduction, subcuta- 
neous division of the tendon of the triceps muscle or subcu- 
taneous section of the olecranon process may be performed 
with orreat advantage. 

Subcutaneous division of resisting structures in close 
proximity to the important vessels and nerves in relation 
with the joint is attended with very great danger and may 
result in very serious consequences. 

Reduction in the, forward and lateral dislocations may be 
accomplished by the same methods as those employed in the 
backward displacement, that is, extension and counter-exten- 
sion in the flexed or straight position, combined if necessary 
with pressure. 

The return of the bones to tlieir normal positions is accom- 
panied by a characteristic sound, and the functions of the 
joint are restored. The re-establishnient of complete flexion 
and extension, and of the normal relations of the olecranon 
process to the condyles of the humerus, will always indicate 
successful reduction of the dislocation. 

Tlie treatment after reduction consists in the local appli- 
cation of remedies to control inflammatory action, and the 
adaptation of an angular splint, with compresses over the 
joint to prevent the recurrence of displacement. 

At the end of a week or ten days, the inflammation having 
sufficiently subsided, passive movements may be carefully 
instituted. 

33* 



S90 DISLOCATIONS. 

Compound dislocations of the elbow are rare, and are the 
result of extraordinary violence. They may be treated either 
by replacement of the displaced bones and closure of the wound, 
partial or complete resection of the bones, or amputation. 
The age, habits, and the state of the general health of the 
patient, with the nature and extent of the injury, will guide 
the surgeon in making a decision as to the best plan of treat- 
ment to be adopted. If the patient is young and in good health 
and the injury slight, an effort may be made to conduct 
treatment by replacing the bones, closing the wound, and 
applying antiseptic dressings. If the injury is more ex- 
tensive, partial resection of the bones may be performed and 
the joint treated by the strictest antiseptic methods. In 
those cases in which injury has been inflicted upon the 
bloodvessels and nerves of the joint, with extensive lacera- 
tions of the muscular structures, amputation should be per- 
formed. 

Several cases of a peculiar form of dislocation have been 
reported, in which a simultaneous luxation of the ulna and 
radius occurs in opposite directions, the former being thrown 
behind and the latter in front of the humerus. It is the 
result of severe violence applied, when the forearm is flexed 
and twisted forcibly upon its axis. The nature of the in- 
jury is recognized by the increase in the antero-posterior 
diameter of the articulation, with a decrease in the trans- 
verse measurement ; also by the presence of a prominence 
both upon the anterior and posterior surfaces of the joint, 
caused by the head of the radius and olecranon process of 
the ulna. The deformity is very striking, the forearm and 
hand being both twisted inwardly and slightly bent. 

Replacement of the dislocated bones may be accomplished 
by extension and counter-extension with flexion, made in 



DISLOCATIONS. 391 

tlie usual way. The ulna is first returned to place and then 
the radius by extension, combined with pressure upon its 
head. 

Radius and Ulna — Inferior Radio-Ulnar Artic- 
ulation — Lateral Ginglymoid This articulation is 

formed by the lower end of the ulna, the rounded articular 
eminence of which is received into the sigmoid cavity on 
the inner side of the lower end of the radius. The bones 
are held together by the anterior and posterior radio-ulnar 
ligaments attaching the margins of the sigmoid cavity to the 
anterior and posterior surfaces of the ulna, with the tri- 
angular interarticular fibro-cartilage, binding the surfaces of 
the lower ends of both bones. The synovial membrane of 
the articulation extends between the articular surfaces of 
the ulna and radius and the lower end of the ulna and the 
interarticular fibro-cartilage. It has been called, from its 
extreme laxity, the membrana sacclformis. The move- 
ment of the articulation is limited to rotation of the radius 
around the head of the ulna, forward and backward, pro- 
ducing pronation and supination. 

Dislocation of the articulation occurs in two directions, yb?'- 
ward and backward. In the former, the anterior radio-ulnar 
ligament witli the synovial membrane and interarticular 
fibro-cartilage are ruptured, the cartilage being torn from its 
attachment to the radius, and sometimes displaced with the 
head of the ulna, which rests on the anterior surface of the 
radius. In the latter, the posterior radio-ulnar ligaments 
with the synovial membrane and fibro-cartilage are lacerated, 
the latter being displaced with the ulna, which is lodged 
upon the posterior surface of the radius. Of the two varieties, 
the backward luxation occurs most frequently. As inde- 
pendent lesions, dislocations of this articulation are very rare ; 



392 DISLOCATIONS. 

they occur frequently in the partial form as complications of 
fracture of the lower end of the radius. 

Causes The cause of dislocation of this joint is the ap- 
plication of violence in such manner as to produce very 
forcible supination or pronation of the hand, as in twists or 
wrenches. 

In ih^ forivard luxation forcible supination of the hand is 
required to dislodge the bone from its articulating cavity, 
and place it upon the anterior surface of the radius. 

In the hackivard displacement, force applied in producing 
extreme pronation of the hand is necessary in order to sepa- 
rate the articular surfaces and place the ulna upon the pos- 
terior surface of the radius. 

Symptoms — The symptoms vary in accordance with the 
nature of the dislocation. In both varieties loss of function 
and deformity are marked. 

The chief symptoms of the forward dislocation are the 
position of the forearm and hand in fixed supination with 
flexion of the fingers and the presence, on the anterior 
surface of tlie forearm, just above the carpus, of a marked 
prominence due to tlie displaced head of the ulna. 

In the backward luxation the symptoms are reversed. 
The forearm and hand are in a state of pronation, and im- 
movably fixed, with slight flexion of the fingers. A promi- 
nence exists upon the posterior surface of the wrist at its 
outer border, formed by the head of the ulna, which is di- 
rected obliquely across the radius. A depression may be 
felt above tlie position of the cuneiform bone, and the styloid 
process and fifth metacarpal bone are not in line, as in the 
normal relations. The breadth of the lower end of the 
forearm is diminished, and the tense tendon of the extensor 



DISLOCATIONS. 393 

carpi ulnaris can be distinctly felt in its course from the 
ulna to the fifth metacarpal bone. 

jyiagnosis If examination of the parts is made before 

the occurrence of much swelling, the nature of the disloca- 
tion can be readily determined. Difficulty may be experi- 
enced in ascertaining the exact character of the displacement, 
when the relation of the parts are altered by accompanying 
fracture. 

Prognosis — In uncomplicated dislocations the prognosis 
is favorable. Repair of the lacei-ated ligaments takes place 
slowly, and care should be exercised in order to avoid re- 
moving the retentive dressings too early. 

Treatment Reduction may be effected in the forward 

displacement by flexing the forearm upon the arm, extend- 
ing, and then forcibly pronating the hand, while pressure is 
made over the head of the ulna to assist in returning it to its 
articulating cavity. 

In the backward dislocation, after flexion of the arm, ex- 
tension of the hand should be made, combined with forcible 
supination. 

The after-treatment should be conducted by the applica- 
tion of compresses over the articulation, in front and behind, 
secured in place by a firm roller, and a Bond's splint, or two 
well-padded straight splints, placed on the anterior and pos- 
terior surfaces of the forearm, and secured likewise by a 
roller. 

Partial dislocation of this articulation is sometimes ob- 
served in persons of feeble constitutions, or in otliers after 
severe injury to the joint, or as a result of a fracture of the 
lower end of the radius in which the treatment has been 
defective. The hand remains in the position of abduction, 
owino; to the relaxed and elon";ated condition of the liga- 



394 DISLOCATIONS. 

ments. Very little can be done in obtaining complete re- 
lief. The repeated application of small blisters over the 
joint might be etfective in overcoming the condition. Sup- 
port, by means of a firm band or a strap made of soft ma- 
terial, should be given to the joint. 

Cakpus — Wrist-Joint — Partial Enarthrodial Ar- 
ticulation — This articulation is formed by the lower end 
of the radius, with the triangular interarticular fibro-cartil- 
age above, and the scaphoid, semilunar and cuneiform bones 
below. A transversely elliptical concave surface is pre- 
sented by the under surface of the radius and fibro- cartilage, 
into which the convex surfaces of the bones of the carpus is 
icceived. The ligaments which fasten the parts together 
are the anterior, posterior, internal, and external lateral. A 
large ^synovial membrane lines the articular surfaces and is 
reflected on the inner surfaces of the ligaments. The arti- 
culation has all of tlie movements of an enarthrodial or ball- 
and-socket joint, except rotation, namely, flexion, exten- 
sion, abduction, adduction, and circumduction. The joint 
is very strong and well protected by the arrangement of the 
articulating surfaces of the bones and the fibro-cartilage, 
with the tendons passing in front and behind, and by the 
styloid processes which project on each side. Dislocation of 
the carpus is an exceedingly rare accident, so much so that 
its existence as an independent traumatic lesion was denied 
by Dupuytren. Later observations have shown that its 
occurrence is possible, and a number of cases have been 
made the subject of clinical study. I have had under my 
care two cases of luxation of the carpus, both of the posterior 
variety, occurring in boys, as the result of falls upon the 
hand, which were reported to the Philadelphia Academy of 
Surgery in March, 1881. 



DISLOCATIONS. 



395 



The dislocations Fig- 186. 

which occur are the 
backward2i.T\di forward : 
in the former, the car- 
pus is placed upon the 
posterior surface of the 
radius and ulna, the pos- 
terior and lateral lig- 
aments having been 
ruptured (Fig. 18G). 
In the latter, the car- 
pus takes a position 
upon the anterior sur- 
face of the forearm 
(Fig. 187), the anterior 
and portions of the lat- 
eral lio^aments havinoj been lacerated. Lateral dislocation 
can only occur when accompanied by fracture of one of the 
styloid processes, and then in the incomplete form. 




Fig. 187. 




Causes Dislocations of the carpus are, as a rule, the re- 
sult of falls upon the hand when it is either in the flexed or 
extended position. 



396 DISLOCATIONS. 

The backward luxation is caused by falls upon the back of 
the hand, producing very sudden and forcible flexion. 

In the forward displacement the force is received upon 
the palm of the hand, causing sudden and forcible exten- 
sion. 

Symptoms — The symptoms of displacement are very 
characteristic — loss of function and deformity are marked. 

In the hachward variety a projection exists upon the 
posterior surface of the lower part of the forearm, with 
another upon the anterior surface of the carpus, increasing 

very greatly the an- 

■^^o- ■^°°' tero-posterior diameter 

of the joint. The 

hand and fingers are 

flexed and only slightly 

movable. The forearm 

is shortened on its 

posterior aspect (Fig. 

188). 

In i\\Q forward dislocation the antero-posterior diameter is 

increased, as in the backward luxation, the carpus, however, 

lying upon the anterior, instead of the posterior, surface of 

the forearm. The hand 
Fig- 189. is markedly extended, 

with strong flexion of 
the fingers, and the 
forearm is shortened 
on its anterior aspect 
(Fig 189). 

Diagnosis, — In most 
cases, before swelling to any extent has supervened, the out- 
lines of the displaced carpus can be readily traced, and the 





DISLOCATIONS. 397 

concave surface of the radius, with the styloid processes of 
both bones, distinguished. 

The condition of flexion or extension of the hand and 
fingers will also assist in determining the position of the 
displaced carpus. 

The differential diagnosis between dislocation of the car- 
pus and fracture of the lower extremity of the radius is 
made by a careful examination of the parts and a study of 
the symptoms. Dislocations are characterized by greater 
deformity, immobility, absence of lateral displacements, and 
crepitus. Reduction, when effected, is permanent. 

Prognosis — The prognosis in dislocations of the carpus 
is favorable, reduction being usually easily accomplished, 
and the functions of the joint, in a short time, fully restored. 

Treatment Reduction is effected by grasping the hand 

and making extension, the movements of extension and 
flexion of the hand, with abduction and adduction being 
executed at the same time and in accordance with the 
direction of the displacement, so as to facilitate replacement. 
Pressure exerted upon the displaced carpus will also assist 
in returning it to place. After reduction, the joint should 
be enveloped in compresses saturated with a lotion of laud- 
anum and lead-water, and the forearm kept upon a well- 
padded anterior splint, held in position by a roller. At the 
expiration of eight to ten days passive motion should be care- 
fully instituted. 

The treatment of coynpound dislocation of the carpus 
should be conducted upon general principles. An effort 
should be made to save, if possible, the hand, the displaced 
bones being returned or excision being performed if neces- 
sary, the wound closed, and antiseptic dressings applied. 
Perfect drainage of the wound should be accomplished. 
34 



398 DISLOCATIONS. 

Where great injury has been inflicted upon the structures of 
the joint, lacerating the bloodvessels and nerves, amputation 
should be performed. 

A number of instances of congenital dislocation have been 
recorded as occurring in this articulation, the displacements 
being in the backward or forward direction. In these cases, 
treatment is of little avail, owing to the degenerative changes 
which have taken place in the structures. 

Carpus — Carpal Articulations — -Arthrodia and 
Enarthrodial Articulations. — The articulations of the 
carpus are divided into those of the first row of carpal bones, 
those of the second row, and those of the two rows with each 
other, the first row being connected by two dorsal, two pal- 
mar, and two interosseous ligaments ; the second by three 
dorsal, three palmar, and two interosseous ; while the two rows 
of bones are united by dorsal, palmar, internal, and external 
lateral ligaments. Tlie articulations of the first and second 
row are arthrodial, while that of the two rows with each 
other is compound, being enarthrodial in the middle, between 
the OS magnum and scaphoid and semilunar bones, and ar- 
throdial on the sides, between the scaphoid and trapezium 
and trapezoid, on the outside, and cuneiform and unciform 
on the inside. (Fig. 190.) The movements betw'een the 
bones of each row are very limited, those between the two 
rows are more distinct, but chiefly limited to flexion and 
extension, while that between different bones of the two rows 
is more extensive, in accordance wnth the character of the 
articulations above described. Two synovial membranes are 
placed between the bones of the carpus and, by their expan- 
sions, cover apposing surfaces. Uncomplicated dislocation of 
the carpal bones is a very rare occurrence. The bones most 
frequently displaced are the os magnum^ semilunar^ ciinei- 



DISLOCATIONS. 



399 



fonii, and pisiform. A few cases of" dislocation of an entire 
row have been recorded — a notable one by Maisonneuve. As 

Fig- 190. 




a rule the dislocation occurs in the posterior direction, the 
bone being placed upon the dorsum, in the complete variety ; 
two cases are reported, one by Prof. Chisolm, of Baltimore, 
in which anterior displacement occurred. 

Causes — Dislocation of the carpal bones takes place as 
the result of falls upon the hand when it is in a state of forced 
flexion, or in the forcible contraction of the hand and fingers 
in grasping the sheet or towel during the pains of labor. 



400 DISLOCATIONS. 

Mr. Cooper records the case of a patient in Guy's Hospital 
who could produce dislocation of the os magnum at pleasure. 

Symptoms — The principal symptom, in dislocation of the 
carpal bones, is the deformity which is caused by the pro- 
jection of the bone from its normal position. 

In luxation of the os magnum the tumor exists at the base 
of the third metacarpal bone, which increases in prominence, 
in flexion of the wrist, and diminishes in extension. A cor- 
responding depression may be felt on the palmar surface of 
the hand. 

When dislocation of the semilunar bone occurs, it produces 
a swelling upon the dorsal or palmar surface corresponding 
to its position in the first row of carpal bones. In the case 
of Prof. Chisolm the displacement was anterior and the 
swelling was just above the last fold of the palmar surface of 
the wrist on a line with the radius. On the dorsal surface 
the tumor would be just below the border of the radius on a 
line with the metacarpal bone of the middle finger. 

Dislocation of the cuneiform bone is exceedingly rare — the 
symptoms attending its displacement are similar to those of 
the other carpal bones. The swelling on the dorsal surface 
would be to the ulnar side of the wrist, and on a line with 
the fifth metacarpal bone. 

In luxation of the pisiform bone it is elevated by the action 
of the flexor carpi ulnaris muscle which is inserted into it. 
Its displacement is due to the inordinate contraction of the 
muscle as in lifting a heavy weight. The position of the dis- 
placed bone can be detected on the anterior surface of the 
ulnar side of the forearm. 

Diagnosis. — The swelling which follows dislocation of the 
carpal bones may be suflicient in some cases to prevent 
recognition of the bone displaced. Ordinarily the bone will 



DISLOCATIONS. 401 

maintain its relation with the metacarpal bones so as to fix its 
position. Sometimes the shape of the bone may be traced. 

Prognosis. — The prognosis in simple dislocation is favor- 
able, restoration and retention being usually easily accom- 
plished. It is sometimes found difficult to retain the pisiform 
bone in place owing to the action of the flexor carpiulnaris 
muscle which has its insertion into it. 

Treatment. — As the dislocations of the carpal bones are 
usually incomplete their reduction should be accomplished 
without much difficulty. It sometimes occurs that the 
swelling which accompanies the accident renders it difficult 
to return the displaced bone, and the efforts of the surgeon 
may be, for a time, unavailing. In effecting reduction of the 
OS magnum, semilunar, or cuneiform bones the hand should be 
extended and pressure should be made on the bone in such a 
direction as to return it to its place. It may be necessary 
to employ continuous pressure by means of the tourniquet or 
other appliances. The manipulations should be made with 
care and in a gentle manner. If inflammation is present, 
local applications should be made to abate it ; after reduction 
the forearm and hand should be supported by an anterior 
and posterior straight splint, a compress having been placed 
over the luxated bone. A roller should be applied to secure 
the dressings in position. At the end of two weeks the 
splints may be removed, and passive movement of the wrist- 
joint carefully made in order to prevent anchylosis. The 
splints should then be re-applied and worn for two weeks 
longer until repair of the ligaments is accomplished. 

Replacement of the pisiform bone may be effected by 
flexing the hand upon the forearm and pushing the bone 
down into place. Efforts should be made to fix it in its re- 
stored position by strips of adiiesive plaster and a bandage, 

34* 



402 DISLOCATIONS. 

the hand being maintained in a flexed condition, over a light 
anterior splint having an obtuse angle at the position of the 
wrist-joint. 

In compound dislocations of the carpal bones it will be 
found necessary, as a rule, to remove the displaced bone. 

Metacarpus — Carpo-metacarpal Articulation of 

THE Fingers — Arthrodia The metacarpal articulations 

of the fingers are formed by the trapezium, trapezoid, os mag- 
num, and unciform of the second row of carpal bones, and the 
bases of the second, third, fourth, and fifth metacarpal bones, 
fastened together by dorsal, palmar, and interosseous liga- 
ments. The synovial membrane is placed between the sur- 
faces of the bones of the articulation and also between the 
bases of the adjacent metacarpal bones, being a continuation 
of that between the two rows of carpal bones. The move- 
ment of the articulations are limited to slight gliding of the 
surfaces upon each other ; the movements of the fifth meta- 
carpal joint are greater than those of the others. 

Carpo- metacarpal Articulation of the Thumb — 
Enarthrodia. — This joint is formed by the trapezium and 
base of the first metacarpal bone, and is inclosed by a 
capsular ligament and lined by a synovial membrane. The 
movements of the joint are flexion, extension, abduction, 
adduction, and circumduction. 

Dislocations of the metacarpal hones of the fingers are 
extremely rare occurrences. One instance of forward 
luxation of all of the metacarpal bones, taken from a cast in 
the Museum of the University College, London, is given by 
Mr. Erichsen. Prof. Hamilton records three cases of back- 
ward displacement, in one of which the metacarpal bones 
of all of the fingers, and in the remaining, the metacarpal 
bones of the index and middle fingers were dislocated. 



DISLOCATIONS. 403 

Dislocations of the metacarpal hone of the tlnimh occur 
rarely in the complete and incomplete form. 

Causes Dislocation of the carpo-metacarpalarticulatioiis 

of the fingers may be caused by direct violence, as in blows 
upon the back of the hand producing ybrit'^rc? displacements; 
or by indirect force, as in blows given with the fist or falls 
upon the closed hand, giving rise to hachward luxations. 

Luxation of the metacarpal hone of the thumh is caused 
by force applied to the posterior surface producing extreme 
flexion or upon the distal end. The direction of displace- 
ment may be hachward or forward, the latter occurring 
very rarely. 

Symptoms The symptoms of dislocation of the meta- 
carpal hones of the fingers are chiefly confined to the 
deformity caused by the displaced bone either upon the 
dorsal or palmar surface in accordance with a hachward or 
foricard dislocation. Pain and loss of function are not very 
marked. The limited mobility of the joint is not materially 
affected. 

The symptoms attending luxation of the metacarpal hone 
of the thumh are more prominent. In the hachward lux- 
ation loss of function is present with marked deformity, 
caused above, by the proximal extremity of the metacarpal 
bone and below, by the trapezium. The position of the thumb 
varies, being either straight or somewhat flexed with slight 
adduction of the metacarpal bone. In X\\q foricard dislo- 
cation the symptoms are less distinct — the displacement 
being usually incomplete. 

Diag7iosis. — If examination is made before the occur- 
rence of swelling when the displaced bone can be felt, the 
nature of the dislocation may be readily determined. A 
number of instances are recorded in which a failure to recog- 



404 DISLOCATIONS. 

nize the conditions was made, the dislocations remaining 
unreduced. 

Prognosis More or less disability remains for a short 

time after reduction in metacarpal dislocations. In those 
which remain unreduced there is marked deformity with 
great impairment of function. 

Treatment — Reduction is effected by making extension 
from the fingers, counter-extension being made from the 
wrist and pressure being exerted upon the bone to force it 
into place. In dislocation of the metacarpal bone of the 
thumb it may be necessary to attach the noose, the prepara- 
tion of which is shown in Figs. 76, 77, and its application, in 
Fig. 191, or Indian puzzle (Fig. 197) in order to exert greater 

Fiff. 191. 




force. After reduction the hand should be placed upon an 
anterior splint with compresses over the articulation and a 
roller to secure both in place. The metacarpal bone of the 
thumb may be readily retained in place by a plaster bandage 
applied in the form of the spica of the thumb. 

Phalanges — Metacarpo - phalangeal Articula- 
tions — Partial Enarthrodial Articulations — These 
articulations are formed between the heads, or digital ex- 
tremities of the metacarpal bones and the bases of the first 
phalanges, tlie rounded surface of the former being received 
into the shallow cavities in the ends of the latter. The 



DISLOCATIONS. 405 

bones are connected by an anterior and two lateral liga- 
ments, a synovial membrane lining the joint. The move- 
ments of these articulations are flexion, extension, abduction, 
adduction, and circumduction. 

Phalanges — Phalangeal Articulations — Gingly- 
MOiD Joints. — These articulations exist between the first 
and second, and second and third phalanges, the flattened late- 
ral condyles of the heads being received into corresponding 
shallow cavities on the bases of the contiguous bones. The 
phalanges are united by an anterior and two lateral ligaments, 
the posterior ligament being supplied by the extensor ten- 
dons as in the metacarpo-phalangeal articulations. The 
movements of the joints are limited to flexion and extension ; 
a slight degree of rotation may be obtained by manipulation. 
Dislocations of the thumb and fingers at the metacarpo-phal- 
angeal and phalangeal 2iVi\Q,u[^i\oxis occur either in the hack- 
ivard OT fortcard direction. The latter luxation takes place 
infrequently, very few instances having been recorded. 

In backward dislocation of the thiimh at the metacarpo- 
phalangeal articulation the anterior and lateral ligaments 

Fig. 192. 




are extensively ruptured, and the head of the first phalanx 
rests upon the posterior and inner surface of the metacarpal 
bone. (Fig. 192.) 



406 DISLOCATIONS. 

At the time of dislocation, the head of the metacarpal 
bone is forced through the anterior ligament, passing between 
the superficial and deep portion of the flexor brevis poUicis, 
the tendon of the flexor longus pollicis, which occupies the 
interval between the two portions, usually being pushed to 
the inner or outer side. From this description of the posi- 
tion assumed by the displaced bone and its relations to the 
surrounding structures it is evident that, so long as the 
points of insertion of the short flexor into the first phalanx 
are intact, it will be difficult to pull the phalanx dow7i and 
over the head of the metacarpal bone. The contraction of 
the fibres of this muscle has a tendency, not only to draw 
the base of the phalanx up, but also to hold it in close con- 
tact with the posterior surface of the metacarpal bone. The 
position of the tendon of the long flexor of the thumb and 
its relation, after the laceration of the tissues, to the dis- 
placed bone are also to be considered. It is possible for it, 
at the time of the dislocation, to slip over the head of the 
metacarpal bone and to grasp it with great power, and by its 
position and the eff'ect it exerts upon the bone, afford an ob- 
struction difficult to be overcome in the efforts at reduction. 
It is to be borne in mind that the first phalanx is the mov- 
able bone, and in reduction the resistance of the muscles at- 
tached to it are to be overcome. The explanation of the 
difficulty encountered in effecting reduction in these cases is 
to be found therefore in the action of the flexor brevis polli- 
cis, and in some instances the peculiar relations assumed to 
the metacarpal bone by the tendon of the flexor longus 
pollicis. 

In dislocation hachward of the fingers at the metacarpo- 
phalangeal articulation, the lateral ligaments are ruptured, 
the anterior being usually intact. The dislocation occurs 
most frequently in the articulation of the index and little 



DISLOCATIONS. 407 

fingers on account of the greater mobility of the joints and 
their more exposed positions. Tlie i)Osition of the phahinges 
in forward dislocation is sliown in Fig. 193. An instance 

Fiff. 193. 




of the forward dislocation of all of the fingers at the meta- 
carpo-phalangeal articulations has been reported by M. Serre, 
of Paris. 

Causes. — The cause of luxation at the metacarpo-phalan- 
geal and phalangeal joints is violence, directly and indirectly 
applied. In the tJiumh, falls upon the posterior surface of 
the last phalanx, producing extreme flexion, may cause 
hachicard luxation. The forward dislocation may be pro- 
duced by making forced extension of the thumb. In the 
fingers, falls upon the last phalanges or the impact of great 
force, as when a base or cricket ball, impelled with great 
momentum, strikes the ends, slightly flexed or extended. 

Syn,pioms. — The symptoms of dislocation of the thumb 
or fingers are usually very prominent. Deformity con- 
stitutes the chief symptom and is easily recognized. Impair- 
ment of function, in some forms of luxation, is quite marked. 
Pain, due to the displacement, is usually slight. 

In the backward metacarpo-{)halangeal dislocation of the 
thumb the deformity is characteristic, the thumb being short- 
ened and turned inward, while flexion of the last phalanx is 
produced by contraction of the flexor longus pollicis. Two 
projections exist on the surfaces, caused by the head of the 



408 DISLOCATIONS. 

metacarpal bone anteriorly, and the base of the first phalanx, 
posteriorly. 

In the /ori^'a7*c? dislocation the position of the displaced 
bone is reversed, and the thumb is either straight, or the last 
phalanx is but slightly flexed. 

Dislocations of the fingers at the metacarpo-phalangeal or 
phalangeal articulations are easily recognized by the symp- 
toms they present. 

Diagnosis, — The facility with which the parts can be ex- 
amined renders the detection of the luxation quite easy. 

Prognosis The great difficulties which are sometimes 

experienced in effecting reduction of the dislocation occur- 
ring at the metacarpo-phalangeal articulation of the thumb, 
and the injury inflicted upon the parts in the violent efforts 
made, render the prognosis doubtful. In the other luxations 
of the thumb and in all of those of the fingers, reduction is 
easily accomplished, and the restoration of the function soon 
takes place. 

Treatment Reduction is effected by extension and 

counter-extension, the latter being obtained by grasping the 

Fiff. 194. 




hand, while the former is made by grasping the finger 
between the thumb and fingers of the surgeon. In reducing 



DISLOCATIONS. 



400 



the displacement tlie finger should be placed in a position 
of forcible extension, and, as traction is made, the phalanx 
should be pressed forward into place. (Fig. 194.) If more 
force is required than can be secured by the fingers of the 
surgeon, appliances devised to retain firm hold of the finger 

Fiff. 195. 




may be employed, as the lever-tractor of Dr. Levis (Fio-. 
195), traction forceps of Charriere (Fig. 196), the double 



Fig. 196. 




noose or clove hitch (Fig. 191), or the Indian puzzle (Fig. 
197). 

In the reduction of dislocation of the thumb at the meta- 
carpo-phalangeal articulation, special manipulations are neces- 
sary on account of the relations assumed by the bones and 
the flexor brevis, and in some cases the tendon of the flexor 
longus pollicis muscle. Various methods have, from time to 
time, been suggested and practised with varying success. 
Extension and counter-extension made with great force 
have failed usually to accomplish reduction. Manipulations, 
35 



410 DISLOCATIONS. 

having for their object the relaxation of the flexor muscles, 
and through this, the release of the imprisoned metacarpal 
bone, have been more successful. 

FiR. 197. 




The method of Dr. Batchelder, of New York, consists in 
grasping the metacarpal bone of the luxated thumb between 
the thumb and finger of one hand and forcing it as far as 
possible into the palm of the hand for the purpose of relaxing 
the flexor brevis pollicis muscle. The thumb of one hand 
should now be placed against the base of the displaced 
phalanx, while with the other hand tiie dislocated thumb 
should be grasped. Forced flexion and extension should 
now be made while pressure is exerted upon the base of the 
phalanx, forcing it downward toward the articular end of the 
metacarpal bone. When, by these combined efforts, the base 
of the phalanx is brought down on a line with the articu- 
lating surface of the metacarpal bone, forcible flexion should 
be made while pressure is still exerted from behind. If not 
successful in returning the bone to its place by this move- 
ment, the thumb should be forcibly extended and pressure 
still be made on the base of the phalanx, the thumb of the 
surgeon maintaining its position acts as a fulcrum, and the 
bone is pressed into place. 

Prof. Crosby's method consists in placing the phalanx 
at a right angle with the metacarpal bone (Fig. 198) and 



DISLOCATIONS. 



411 



Fis. 198. 



pressing the base forward into place. In order to accom- 
plisli this he places the hand of the patient on his knee, 
elevates the phalanx to a point 
slightly beyond the perpendicular, 
and grasps the base between his 
thumbs placed behind, and his 
index fingers in front. With 
this hold of the base of the bone 
great pressure can be exerted, 
forcing the base of the phalanx 
downward and forward until it 
glides over the head of the meta- 
carpal bone. In cases in which 
all other methods fail subcuta- 
neous section of the tendons of 
the flexor brevis muscle may be 
performed with great advantage. 

Great care should be exercised in making forcible efforts at 
reduction. Very serious consequences have followed violent 
and injudicious attempts, sucli as erysipelas and gangrene. 
In one instance the thumb was torn off during forcible and 
long-continued efforts. 

Reduction in the forward luxation may be accomplished 
by making extension followed by forcible flexion. If this 
plan is not successful, the phalanx may be placed in a posi- 
tion of forced extension and traction then employed. 

Compound dislocations of the thumb and fingers should 
be treated in the same manner as those occurring in con- 
nection with other joints. Tetanus frequently follows the 
accident when much laceration of the soft parts has taken 
place. 




412 dislocatioxs. 

Pelvis. 

Sacruisi and Ilium — Amphtarthrodial Articula- 
tion This joint is formed by the lateral surfaces of the 

sacrum and ilium connected by the anterior and posterior 
sacro-iliac ligaments. During early life, occasionally in the 
adult, and in the female during pregnancy, the articulation 
is lined by a delicate synovial membrane. The movements 
of this articulation are very limited, occurring, to but a very 
slight degree, in any direction. 

Sacrum and Coccyx — Amphiarthrodial Joint 

This articulation resembles those of the vertebra?, being 
formed between the oval concave surface on the apex of the 
sacrum and the oval surface on the base of the coccyx. The 
ligaments are the anterior and posterior sacro- coccygeal and 
the interarticular fibro-cartilage. 

A synovial membrane is found to exist usually during 
pregnancy. The movements of the articulation are limited to 
gliding in the forward and backward direction. "\^"hen much 
motion exists the cavity is lined by a synovial membrane. 

PuBEs — Amphiarthrodial Articulation This joint 

is formed by the apposition of the two oval surfaces on the 
inner extremities of the pubes, held together by the anterior, 
posterior, and superior pubic with the sub-pubic ligaments 
and interarticular fibro-cartilage. The movements of this 
articulation, which occur in but a very limited degree in any 
direction, are much increased during pregnancy, owing to 
changes which take place at that time between the surfaces 
of the plates of the interarticular fibro-cartilage. An inter- 
mediate fibrous elastic tissue connects the two plates, except 
at the upper and back part of the articulation, where it is 
absent, and the surfaces of the fibro-cartilaginous plates are 



DISLOCATIONS. 413 

lined by synovial membrane. In some instances, the elastic 
tissue is entirely absent, permitting the synovial cavity to 
extend the entire length of the cartilages, and giving, as a 
result, greater latitude of movement to the articulation. 

Dislocations, usually incomplete in form, may occur at any 
of the articulations above mentioned. They are generally 
associated with fracture or injury to the bloodvessels and 
viscera of the pelvis. In sacro-iliac dislocations the dis- 
placement of the ilium is upward and backward. In the 
sacro-coccygeal luxation it may be either in i\\Q forward or 
backward direction, while in separation of the pubes the 
bone of either side may be displaced in the forward or back- 
ward direction. Where the separation of the articulating 
surfaces is extensive the ligaments are ruptured ; usually 
they escape laceration, but are subjected to great tension. 

Causes. — Great violence applied directly is necessary to 
cause separation at the sacro-iliac and pubic articulations, 
as crushes by heavy masses of earth, rockj or coal, between 
the drawheads of railway cars, or between a wall and a wagon 
in motion. It may be also produced by violent kicks or 
blows directly over the parts. A case is reported by Dr. 
Thomas Harris, of this city, in wdiich partial dislocation of 
both sacro-iliac and pubic articulations occurred in a woman 
as the result of a blow, by her husband, with the fist, de- 
livered upon tlie sacrum. During pregnancy, in some in- 
stances, the ligamentous structures of the pubic joint become 
relaxed and softened, so as to permit dislocation, in the 
incomplete form, upon the application of slight force. In- 
stances are recorded in which separation, with but slight 
displacement, has occurred during parturition. 

Sacro-coccygeal dislocations may occur from the appli 
cation of force applied externally, as in kicks or falls upon 

35* 



414 DISLOCATIONS. 

the buttocks, or internally, by the pressure exerted by the 
child's head in its passage through the pelvis, during par- 
turition. 

Symptoms The symptoms of unilateral dislocation of 

the sacro-iliac junction, in which the displacement back- 
ward is extensive, are usually well marked. Pain, loss of 
function, and deformity, are very prominent. The pain is 
very severe, and prevents recumbency upon the back. The 
limb of the affected side is shortened, and its function is 
greatly impaired by reason of injury to the sacral nerves. 
Deformity is caused by the projection upward and backward 
of the posterior border and crest of the ilium, and the tuber- 
osity of the ischium occupies a higher position than that on 
the sound side. Severe contusion of the soft parts usually 
accompanies the injury, and the patient is unable to pass 
his urine. 

In pubic dislocations, due to traumatism, the symptoms 
relate principally to the condition of the pelvic organs, 
which are usually seriously involved. In extensive separa- 
tion of the articulating surfaces the deformity is well marked. 
Pain is sometimes very pronounced and increased on move- 
ment. 

The symptoms of sacro-coccygeal luxations are similar, 
in some respects, to those of the sacro-iliac junction. Pain 
is very marked and constant, and is increased on defecation. 
Tenesmus is present, with retention of urine. The displace- 
ment, whether in the backward or forward direction, may 
be recognized on inspection. 

If the former exists, a prominence will be felt over the 
region of the articulation ; and if the latter, a depression 
can be outlined with the fino-er. In some instances a late- 



DISLOCATIONS. 415 

ml displacement may occur, as in the case reported by Dr. 
Roeser. 

Diagnosis. — A careful examination of the parts is usu- 
ally necessary to detect the displacements occurring in dif- 
ferent forms of pelvic dislocations. Occasionally the swell- 
ing, which rapidly supervenes, obscures the symptoms and 
increases the difficulty in making a diagnosis. In disloca- 
tions of the coccyx, the nature of the injury can be detected 
by introducing the finger into the rectum and making, in 
this way, an exploration of the parts. 

Prognosis The violent injury inflicted upon the con- 
tents of the pelvic cavity and surrounding structures in dis- 
location of the pelvic articulations renders the prognosis un- 
favorable. More or less disability, with pain, remains after 
the occurrence of the injury. The sacro-coccygeal articu- 
lation becomes the seat, sometimes, of a very painful and 
persistent neuralgic affection. In some cases reduction 
of the dislocations in the various joints cannot be effected, 
and the deformity is not removed. 

Treatment — In sacro-iliac and puhic dislocations, reduc- 
tion is accomplished by pressure and counter-pressure made 
on opposite sides of the pelvis. In luxations of the coccyx, 
pressure can be exerted by introducing the finger of one 
hand into the rectum, and bringing it in contact with the 
bone, while counter-pressure is made with the fingers of the 
other hand placed on the outside. After reduction, the pel- 
vis should be surrounded by a broad bandage, firmly applied, 
and the patient should rest in bed for ten days, two weeks, 
or longer, if necessary. Careful attention should be given to 
the functions of the rectum and bladder. Defecation is 
usually painful and is accomplished with effort, and should 
be assisted by enemata, in order to prevent recurrence of 



416 DISLOCATIONS. 

tlie displacement. The catheter should be used twice or 
thrice a day to relieve the bladder. Pain should be re- 
lieved by anodynes, and inflammation should be treated by 
the local application of sorbefacients and fomentations, as 
well as by the internal administration of appropriate reme- 
dies. It may be necessary, in some cases, to wear a ban- 
dage for some time to afford support to the parts. 

Lower Extremity. 

Dislocations of the lower extremity may be divided into 
those of the femur, patella, tibia, fibula, tarsus, metatarsus, 
and phalanges. 

Femur — Hip-joint (Coxo-femoral) — Enarthro- 
DiAL OR Ball-and-Socket Joint — This articulation is 
formed by the femur and os innomatum, the large globular 
head of the former being received into the deep, cup-shaped 
cavity, the acetabulum, situated upon the external surface 
of the latter, near its middle. The ligaments of the joint 
are 4he capsular, a strong ligamentous capsule inclosing the 
articulation ; the ilio-femoral or Y ligament, a reinforcing 
band taking origin, above, from the anterior inferior spine 
of the ilium and being inserted, below, into the anterior 
inter-trochanteric line, crossing the joint obliquely from 
above, downward, and inward ; the ligamentum teres, a tri- 
angular fibrous band, attached by its base to the margins of 
the notch at the bottom of the acetabulum, its fibres uniting 
with those of the transverse ligament, and by its apex to the 
ovoid depression, situated a little behind and below the 
centre of the head of the femur ; the cotyloid ligament, a 
fibro-cartilaginous rim fastened to the border of the acetab- 
ulum, and the transverse ligament which crosses the cotyloid 



DISLOCATIONS. 417 

notch, and converts it into a foramen. A large synovial 
membrane covers the interior of the joint. A number of 
muscles are in relation with the articulation, some of which 
take part in the displacements occurring in connection with 
dislocations of the joint. The movements of the articulation 
are very extensive and occur in all directions, as extension, 
flexion, abduction, adduction, circumduction, and rotation. 

Owing to the very secure manner in which the head of 
the femur is lodged in the acetabular cavity by reason of its 
depth, the large contact of articulating surfaces, the ar- 
rangement of the strong ligaments of the articulation, and 
the protection afforded by the powerful muscles in relation 
with the joint, complete dislocation is accomplished only, as 
a rule, after the application of extreme and sudden vio- 
lence. In the complete separation of the articular surfaces 
extensive laceration of the ligamentous and muscular struc- 
tures occurs. Of the ligaments, the capsular and ligamentum 
teres are ruptured, the former usually in that portion not pro- 
tected by the ilio-femoral or Y ligament. In dislocations, 
the result of extraordinary violence, producing the rarer 
forms of displacement, the ilio-femoral ligament is also torn. 
The muscles in immediate relations with joints, and those at- 
tached to the trochanter major especially, are liable to be 
ruptured. The larger muscles, and those whose insertions 
are more remote from the head, on this account affording 
them more play, escape laceration. With the exception of 
the great sciatic nerve, the large vascular and nerve trunks 
are not involved in hip-joint luxations. In some instances, 
severe contusions of the soft parts accompany the acci- 
dent. A number of instances of spontaneous dislocation of 
the hip-joint have been recorded, in which the displacement 



418 DISLOCATIONS. 

is always incomplete and unattended by rupture of the cap- 
sular ligament. 

Dislocations of the hip-joint occur next in frequency to 
those of the shoulder-joint and second in the list of luxations 
of the different joints of the body. Of 491 cases collected 
by Malgaigne, 321 occurred in the shoulder and 34 in the 
hip. According to the statistics of the Pennsylvania Hos- 
pital, as reported by Prof. Agnew, 89 cases of hip-joint lux- 
ations occurred in 912 cases of dislocations admitted into the 
Hospital. 

The same causes which determine the occurrence of 
other injuries in males and females exist in hip-joint dis- 
locations, males suffering always in very much Lrger pro- 
portion than females. 

Age has also an important influence. Of the 89 cases 
taken from the records of the Pennsylvania Hospital 78 
were males and 11 females; 39 occurred between the ages 
of fifteen and twenty-five years, 26 between twenty-five 
and thirty, 12 between thirty-five and forty-five, 6 between 
forty-five and fifty-five, 5 between fifty-five and sixty-five, 
and 1 between sixty-five and seventy-five. According to the 
table of Prof. Agnew, given above, luxation of the joint is 
most frequent ^between fifteen and twenty-five years of age. 
Prof. Gross states that dislocation often occurs between the 
ages of twenty and twenty-five, but is most frequent from the 
thirtieth to the forty-fifth year. Two cases of hip-joint dislo- 
cation are reported as occurring in children at the age of six 
months, and five cases, from the records of the Pennsylvania 
Hospital, between seventy-five and eighty-five years of age. 
The absence of muscular power in the very young and its 
loss, with a condition of fragility of the bones, conducing to 



DISLOCATIONS. 419 

fractures, in the old, contribute to the infrequent occurrence 
of dislocations at tliese periods of life. 

The results of the investigations of Mr. Henry Morris of 
London, published in 1877 in the Medico-Ghirurgical Trans- 
actions, have shown that abduction of the limb is the position 
most favorable to the occurrence of dislocations of the hip- 
joint, the head of the femur being largely displaced from 
the acetabulum while the limb is abducted. The conclu- 
sions, arrived at by Mr. Morris, have been confirmed by 
him by experiments made upon the cadaver, as well as by 
clinical observations. They are not, however, accepted by 
others who have made special study of the subject. 

Varieties of Displacement. — Dislocation of the head of 
the femur may take place in four different directions : back- 
ward and upward, upon the dorsum of the ilium, iliac dis- 
location ; backward and upward, into the great sacro- 
sciatic or ischiatic foramen, sciatic ov ischiatic ; forward 
and downward, into the obturator or thyroid foramen, obtu- 
rator or thyroid; forward and upward on the pubes, pubic. 
Variations, to slight degree, in the positions assumed by the 
head of the femur in the four principal forms described may 
occur ; practically they exert but little or no influence. 

Of the chief forms above mentioned, dislocation upon the 
dorsum ilii occurs most frequently, next, that into the ischiatic 
foramen, then, tlie thyroid variety, and finally, the pubic, 
which occurs quite rarely. The relative frequency is shown 
in the cases collected by Prof. Hamilton, who gives, out of 
lOJ^ instances, oo iliac, 28 ischiatic, 13 thyroid, and 8 pubic. 
The same order of occurrence appears in the table prepared 
by Mr. Bryant from the records in Guy's Hospital. 

A number of instances of simultaneous dislocations of the 
hip-joint have been reported ; in some, the luxation was in 



420 DISLOCATIONS. 

the same direction and position ; in others, they have 
varied, one being an iliac dislocation and the other a thy- 
roid. 

The frequent occurrence of the posterior displacement is 
to be explained in the manner, in which, and the direction, 
from which, the vulnerating force is applied, as well as the 
attitude of the limb at the time of the impact of the force. 
In most instances, the violence is applied from the front, 
upon the foot or knee, the limb being at the time advanced 
causing flexion of the thigh upon the pelvis and in a state 
of abduction and internal rotation. Under such conditions, 
the force would be conveyed through the bone upon its head 
in such direction as to project it backward and upward upon 
the dorsum of the ilium. Force applied in the same way, 
with the femur still more flexed, would be liable to produce 
dislocation backward and downward into the sciatic 
foramen. 

Causes — As stated above, extreme and sudden violence 
is necessary to dislodge the head of the femar from the ace- 
tabulum. This may be applied directly or indirectly, in the 
latter manner more frequently than in the former ; as in falls 
upon the knee or foot, by crushes by heavy weights upon 
the back, the tliighs being flexed and Avidely separated, or 
twists of the pelvis, while the lower extremity is fixed. 

In the iliac dislocations, the causes are usually falls upon 
the knee or foot, the limb being advanced, the thigh flexed, 
abducted, and rotated internally. 

In the ischiatic luxation the causes are the same as those 
concerned in the production of the iliac variety. When 
ischiatic displacement occurs, however, the thighs are at a 
greater degree of flexion, exceeding that of a right angle, 
the limb abducted, and rotated strongly internally. 



DISLOCATIONS. 421 

Thi/roid dislocations are caused by falls upon tlie knee or 
foot, the limb being markedly abducted and drawn back- 
ward, and rotiiled outward. They may also occur as the 
result of the impact of great force upon the hip, while the 
body is bent forward, the limb being abducted and re- 
tracted. 

Pubic luxations occur as the result of force applied in the 
same manner as in thyroid dislocations, the limb being 
abducted and retracted. Heavy weights upon the shoulders 
which fix the trunk, assist in the production of this form of 
displacement. It may also occur when the thighs are firmly 
held and the trunk is bent forcibly backward. A notable 
case is reported by Mr. Ure, of London, in which this form 
of dislocation occurred in a swimmer, while vigorously 
" striking out" in the act of swimming. 

The position of the limb, in the various dislocations above 
mentioned, has been de.<cribed as that of abduction, as 
given by Mr. Morris, with flexion and rotation. Others 
describe the position as that of adduction. Rotation, either 
internal or external, is an important factor in determining 
the dislodgment of the head of the femur and the direction 
taken by it subsequeiilly. Abduction, with flexion and in- 
ternal rotation, will determine a backward displacement of 
the head of the femur, the luxating force continuing to act. 
Abduction, with extension and external rotation, will ac- 
complish a forward displacement, the i'orce continuing to 
act. It would seem natural that, in a vast majority of in- 
stances, the head of the bone should escape at the anterior 
inferior portion of the capsule, where the rim of the acetab- 
ulum is deficient, its place being supplied by the transverse 
ligament. After its exit from the capsule, or while in 
progress of dislodgment, the bone is carried anteriorily or 
36 



422 



DISLOCATIONS. 



posteriorily, in accordance with the position of the limb 
while the force is exerted upon it. 

Symptoms — Pain, loss of function, deformity, and immo- 
bility characterize all of the forms of hip-joint dislocation. 
The individual luxations are distinguished by variations in 
the symptoms peculiar to each form. 

Iliac Dislocation — In this variety the displaced bone is 
placed in the lower part of the iliac fossa, beneath or upon 

the gluteus minimus mus- 
Fig-lSS. cle (Fig. 199). In the 

dislocation, rupture of 
the capsular and round 
ligaments occurs with 
great tension and some- 
times laceration of the 
obturator externus and 
internus, the gemelli, the 
pyriformis, and quad- 
rat us femor's muscles. 
The gluteal, adducters, 
and pectineus, with the 
muscles inserted into the 
lesser trochanter, are re- 
laxed. Pain is present 
and increased at efforts 
of movement ; impairment of function is very great, and the 
limb is fixed in its position. The deformity is very promi- 
nent, affecting the appearance of the entire limb. The 
position of the head of the femur upon the external surface 
of the ilium renders the hip very prominent. In persons, 
not too corpulent, it may be felt moving during rotation of 
the thigh. The trochanter major is in much closer rela- 




DISLOCATIONS. 



423 




Fi?. 200. 



tion with the anterior superior spinous process than normal. 
The thigli is Hexed upon the pelvis and the leg upon tlie 
thigh. The limb is markedly adducted, the knee, when the 
patient is in the erect position, is advanced beyond that of 
the opposite side and elevated above it. Tiie foot is 
strongly inverted, the heel raised from the floor, the base of 
the great toe resting upon the inner 
side of the tarsus of the opposite foot 
with the point of the toe directed ob- 
liquely across the foot. (Fig. 200.) 
Tlie movements of flexion and ex- 
tension can be made to very slight 
extent, adduction to much greater 
extent, while abduction cannot be 
accomplished without great effort and 
accession of pain. Shortening of the 
limb exists from one to two and a 
half inches. 

Fig. 201. 




Ischiatic or Sciatic Dislocation — In this form of dis- 
placement, the head of the bone is thrown haclcward and 
slightly upward into the sciatic foramen, occupying its 
lower portion, and resting upon the lesser sacro-sciatic liga- 
ment, in its middle upon the pyriformis muscle, or in its upper 
portion between the upper border of this muscle and the 



424 



DISLOCATIONS. 



margin of the ilium. (Fig. 201.) The capsular and teres 
ligaments are ruptured, while laceration, to a greater or less 
extent, of the gluteal, obturators, gemelli, and quadratus 
femoris muscles may occur, tlie psoas and iliacus heing ren- 
dered very tense. The symp- 



Fij?. 202. 




toms, in general, of this va- 



riety resemble very closely 
those of the iliac dislocation, 
being somewhat less in degree. 
The position of the displaced 
head of the bone is nearer to 
the normal articulating cavity, 
and therefore the changes in 
the relations are not so great. 
The lodgment of the head in 
the sciatic foramen renders it 
less prominent and difficult 
to outline ; the great tro- 
chanter is not so near to the 
anterior superior spinous pro- 
cess as in the iliac luxation ; 
the flexion of the thigh and 
leg is not so marked ; the ad- 
duction of the limb and the 
advancement of the knee and 
its elevation above that of the sound side are less. The heel 
of the foot of the injured side is slightly raised, and the great 
toe rests in contact with the inner side of the opposite foot 
at the metacarpo- phalangeal articulation of the corresponding 
toe. (Fig. 202.) The shortening of the limb is much less, 
not exceeding usually an inch. The immobility of the limb 
is very marked, greater than in iliac displacement, and its 



DISLOCATIONS. 425 

movements are very much restricted. If the patient is placed 
in the recumbent position, and extension of the thigh made, 
the back is arched ; this condition disappears on flexion. 
Sometimes pressure is exerted by the head of the bone upon 
the great sciatic nerve, producing pain and numbness. 

Thyroid Dislocation In the thyroid dislocation the head 

of the femur is thrown forward and downward into the ob- 
turator or thyroid foramen, where it rests upon the obturator 
externus muscle. (Fig. 203.) The capsular ligament is 

Fig. 203. 




ruptured, the teres sometimes e-^caping, as shown in a dis- 
section made by Prof. Agnew. Tiie gluteal muscles, with 
the pyriformis are rendered tense, giving to the hip a flat- 
tened a[)pearance. The great trochanter is placed down- 
ward and in front of the acetabulum resting upon its lower 
margin, in which position it is widely removed from the an- 

36* 



426 



DISLOCATIONS. 



Fiff. 204. 



terior superior spinous process of the ilium. The limb is 
markedly abducted, and advanced, the heel of the foot raised 
and the toes, sometimes everted, are in contact with the floor. 
The limb is lengthened from an inch 
and a half to two inches. The tension 
of the psoas and iliacus muscles causes 
the patient to incline the body to the 
affected side. (Fig. 204.) In most 
instances the head of the bone can be 
felt in its abnormal position. 

Pubic Dislocation The displace- 
ment of the head of the femur upon 
the ramus of the pubes is a very rare 
accident, occurring, as stated above, in 
eight instances only out of one hundred 
and four hip-joint dislocations. The 
capsular and teres ligaments are rup- 
tured and the muscles, inserted into the 
great trochanter, are made very tense. 
In some instances they are lacerated. 
The head of the bone lies beneath the 
psoas and iliacus muscles, which are 
stretched over it, and forms a marked 
tumor in the groin which can be 
readily felt. Its position is usually 
between the pubic eminence and the 
femoral vessels wJiich lie to the inner 
side. (Fig. 205.) The flattening of the hip is present as 
in the thyroid luxation. The limb is slightly flexed, short- 
ened from a half to one inch, strongly abducted, and 
everted. The toes of the foot are in contact with the floor 
and turned out : the heel is raised to a slight extent. (Fig. 




DISLOCATIONS. 



427 



20G.) Adduction and internal rotation of the limb cannot 
be executed on account of the fixed position of the head of 
the bone upon the ramus of the pubes. 



Fi?. 205. 



Fig. 206. 





Diagnosis Altliough the symptoms of the various forms 

of hip-joint dislocations are prominent and distinctive, yet 
the importance of avoiding error in making a diagnosis is 
so great that, in every case of suspected luxation, the patient 
should be subjected to the most critical examination. For 
this purpose he should be examined first in the erect position, 
with all clothing removed, and then he should be placed in 
bed, and an anaesthetic should be administered until complete 
anaesthesia is produced. The examination should be con- 



428 DISLOCATIONS. 

ducted by inspection, mensuration, and manipulation of the 
parts. Inspection will enable the surgeon to ascertain the 
character and extent of the deformity ; by mensuration he 
can establish the existence of the disturbed relations of promi- 
nent fixed points, and by manipulation he may be able to dis- 
tinguish the position of the displaced head of the bone or 
the presence of the diagnostic signs of other lesions. The 
examination must have for its object not only the distinction 
of the dislocation from other lesions which may present in 
some respects analogous symptoms, but also the differentia- 
tion of the various forms of hip-joint luxations. 

Measurements of the parts or limbs are best made by a 
tape, graduated measure, or rule. In ascertaining the exist- 
ence of shortening or lengthening, the measurements should 
be made from the apex of the ensiform cartilage to the sole 
of each foot, placed at right angles to the leg, or from the an- 
terior superior spinous process of the ilium to the internal 
condyle of each femur. The measurements may also be 
taken, in those forms in wiiich it is possible, chiefly the sciatic, 
when the limbs are flexed at right angles to the trunk, the 
patient being in the recumbent posture, as suggested by Dr. 
Allis, of this city. In this position of the thighs the shorten- 
ing is made very apparent. The extent of the change in the 
position of the great trochanter to the fixed points of the pelvis 
may be determined by measurements with the rule or tape. 

The method of examination suggested by Nelaton may be 
employed with great advantage in determining its relations 
in the posterior displacements. The method consists in 
flexing the thigh at a right angle to the pelvis and drawing 
a line from tlie anterior superior spinous process of the 
ilium to the most prominent part of the tuberosity of the 
ischium; this will cross tlie cavity of the acetabulum, divid- 



DISLOCATIONS. 429 

ing it into two equal portions and touch tlie top of the tro- 
chanter major. Displacement may be inferred to exist if 
the trochanter projects to a notable degree above this line, 
fracture of the neck of the femur being absent. 

The different lesions which present symptoms resembling 
in some particulars those of recent dislocations of the hip- 
joints are fractures of tlie neck of the femur., of the acetabu- 
lum, or of the great trochanter, contusions of the great tro- 
chanter and joint, and in old luxations, coxalgia in certain 
of its stages. In these cases the differential diagnosis is 
made by a careful study and comparison of the symptoms 
present. The existence of fracture may be determined by 
mobility and crepitus, of contusions, by the perfect move- 
ments of the articulation under ana3sthesia and of coxalgia, 
by a careful inquiry into the history of the case and exami- 
nation of the joint, if necessary, under anaesthesia, to ascer- 
tain the position of the head of the femur and the move- 
ments of the articulation. 

The position of the displaced head of the bone can, in 
most varieties, be felt by making pressure with the fingers 
over the region occupied by it. In emaciated subjects its 
movements may be seen. In one form — the sciatic — it may 
be felt through the walls of the vagina or rectum, the finger 
being introduced for this pur-pose. 

The late Professor Gross suggested, in cases of doubt, the 
exploration of the cavity of the acetabulum with a long, 
sharp pointed needle. The passage of this into a deep cav- 
ity in the normal position of the acetabulum would indicate 
the absence of the head of the bone. While he deemed the 
procedure devoid of danger and of value as a means of diag- 
nosis, he thought it rarely necessary in any case, the symp- 
toms being usually too prominent to elude detection. 



^30 



DISLOCATIONS. 



For the purpose oF convenient examination and study, the 
symptoms of the various forms of hip-joint dislocations may 
be presented in tabular form, as follows : — 



Backward and Upward. 

1. Iliac ; dorsum ilii. 

2. Sciatic ; sciatic foramen. 

Hip : Prominent. 

Iliac; great trochanter: Very 
conspicuous and closer to an- 
terior superior spinous pro- 
cess of ilium than normal. 

Sciatic : Very prominent ; lower 
down and more remote from 
anterior superior spinous pro- 
cess than normal. 

Iliac : Limb firmly fixed in ab- 
normal position ; inverted : 
thigh flexed upon pelvis, leg 
upon thigh ; knee in advance 
and above that of. opposite 
side ; foot raised from floor, 
inverted ; great toe resting on 
inner side of tarsus of other 
foot ; limb shortened IJ^ to 2% 
inches. 

Sciatic: Same as iliac, except 
less in degree ; limb tshorteu- 
ed 3^ to 1 inch ; shortening 
very perceptible on flexing 
both thighs at right angles to 
the trunk, the patient being 
recumbent; arching of back 
on making extension of thigh; 
great toe rests against the 
ball of opposite foot ; toes in 
contact with floor; heel raised. 

Iliac : Head of femur easily felt 
on dorsum ilii, especially in 
lean subjects. 

Sciatic: Concealed in sciatic 
foramen; difiicult to detect; 
maybe felt through walls of 
vagina or rectum. 



Forward and 
Downward. 
Thyroid; thyroid fora- 
men. 

Flattened. 

Not prominent ; re- 
mote from anterior 
superior spinous 
process. 



Limb fixed ; slightly 
flexed ; abducted ; 
advanced; knee 
lower than opposite; 
toes on the floor ; 
heel raised ; foot 
slightly everted or 
straight; widely se- 
parated from other 
foot; limb length- 
ened from l}4 to 2 
inches. 



Head of bone forms a 
distinct tumor in 
thyroid foramen, 
felt more easily in 
thin subjects. 



Forward and 

Upward. 

Pubic ; on ramus of 

pubes. 

Flattened. 

Difiicult to detect its 
position: depressed; 
nearer middle line 
of body than nor- 
mal. 



Limb fixed; abducted; 
everted ; thigh flex- 
ed on pelvis; leg on 
thigh ; knee nearly 
in line with oppo- 
site ; foot everted ; 
ball of toes on floor; 
heel slightly raised; 
limb shortened 3^ to 
1 inch. 



Head of bone seen and 
felt in groin just 
above Poupan's 

ligament. 



DISLOCATIONS. 431 

Proff7iosis. — In uncomplicated recent dislocations of the 
hip-joint, the prognosis, as to reduction and restoration of 
the functions of the joint, is favorable. In luxations asso- 
ciated with fracture of the acetabulum or of the femur, 
difficulty may be experienced in effecting reduction, and more 
or less disability may remain. Fracture of the femur may 
occur during attempts at reduction, especially in old lux- 
ations, and serious injury may be inflicted upon the sciatic 
nerve in obtaining replacement in the ischiatic variety, re- 
sulting in permanent paralysis of the muscles supplied by it. 
In old unreduced dislocations the functions of the joint may 
be, to a certain extent, restored. 

Treatment. — Reduction of the various forms of hip-joint 
dislocations may be effected by manipulation or by extension 
and counter-extension. 

Reduction by Manipulation Although this plan had been 

employed by Prof. Nathan Smith and others occasionally, it 
was not generally adopted or practised as a systematic 
method until 1852, when Dr. W. W. Reid, of Rochester, N. 
Y., published a paper upon reduction of the backward and 
upward dislocations of the femur by a definite method of 
manipulation. He regarded the difficulties encountered in 
the reduction of hip-joint luxations as due to muscular con- 
traction, and the principle upon which his method was 
founded, consisted in securing by manipulation the relaxation 
of these structures. Later experiments in 1853, by Prof. 
Moses Gunn, showed that the muscles did not participate to 
any marked extent in offering resistance to the return of the 
displaced bone, but that the impediment rested chiefly, if not 
altogether, in the untorn portions of the capsular ligament 
which held the head firmly in its displaced position, and 



432 



DISLOCATIONS. 



that reduction by forcible extension was only accomplished 
by causing laceration of this portion. 

Reduction by manipulation, he claimed, could be easily 
effected " by placing the limb in such position as will effec- 
tually approximate the two points of attachment of that por- 
tion of the ligament which remains untorn." 

In 1869 Prof. Henry I. Bigelow published an elaborate 
monograph upon the Mechanism of Dislocation and Fracture 
of the Hip, in which he recognized the " anterior portion of 
the capsular ligament as the exponent of the total agency of 

the capsule in giving position 
Fig. 207. to the dislocated limb, and, 

what is more important, as so 
identified with the pheno- 
mena of luxation, that reduc- 
tion must be accomplished 
almost wholly wnth reference 
to it." The anterior portion 
of the capsular ligament is 
composed chiefly of the ilio-fe- 
moral ligament, which takes 
its origin from the anterior 
inferior spinous process of the 
ilium, and crossing downward 
to the front of the femur is 
inserted by two fasciculi into 
nearly the whole of the ante- 
rior intertrochanteric line, be- 
ing about half an inch wide 
at the point of origin and two 
inches and a half wide at its 
insertion. It resembles an inverted Y ^^^ "^^as designated 




DISLOCATIONS. 433 

by Prof. Bigelow as the Y-lJJ5«'^"^ent. (Fig. 207.) It 
is very strong, being nearly a quarter of an inch in thick- 
ness, and in experiments made, required for its rupture the at- 
tachment of weights ranging from two hundred and fifty to 
seven hundred and fifty pounds. It forms an *' unyielding 
suspensory band by which the femur when in a state of ex- 
tension as in walking is forcibly retained in its socket." 
The function of the internal or anterior branch is that of 
limiting the extension of the femur, while the external or 
posterior limits the eversion. This ligament, as stated above, 
plays an important part in the mechanism of hip-joint dis- 
locations, and in the manipulations, to effect reduction in the 
various displacements, the limb should be placed in such 
positions as to relax this band and utilize it in replacing the 
head of the bone. This is accomplished chiefly by flexion, 
which is the important element in all manipulative efforts. 

The different steps in reduction by manipulation arejlex- 
1071, adduction or abduction, rotation, and circumduction. 

In iliac dislocations reduction by manipulation is effected 
in the following manner : The patient should be placed on 
a low bed upon a firm mattress, or preferably upon the floor, 
and anaesthesia should be produced. The surgeon standing 
or kneeling by his side should grasp the ankle with one hand 
and the knee with other, and flex the thigh upon the pelvis 
and the leg upon the thigh. The limb should now be ad- 
ducted, slightly rotated outward, and then carried outward 
by external circumduction across the abdomen and placed 
in its natural position by the side of its fellow. 

The method hy traction, as designated by Prof. Bigelow, is 

executed as follows : *' Lay the patient, when etherized, on 

his back upon the floor, flex the leg upon the thigh, the thigh 

upon the abdomen, adduct and rotate it a little inward to 

37 



434 DISLOCATIONS. 

disenoragre the head of" the bone from behind the socket. The 
Y -ligament is then relaxed. If the bone can now be ab- 
ducted beyond tlie perpendicular, the capsule and other tis- 
sues are so torn or relaxed that reduction may be accom- 
plished without difficulty. The thigh need only be forcibly 
lifted or jerked toward the ceiling, with a little simultaneous 
circumduction and rotation outward, to direct the head of the 
bone toward the socket." Traction may also be performed 
by placing the foot, divested of the shoe, on the anterior supe- 
rior spinous process of the ilium, or on the pubes while the 
flexed knee is drawn up. 

Reduction may also be effected hy flexion, abduction, and 
rotation outtcard, performed in the order named. Flex the 
thigh, abduct or circumduct it outward and rotate it out- 
ward. A little consideration will explain the effect of these 
movements upon the head of the displaced bone. By flex- 
ion the muscular and ligamentous structures are relaxed. 
Abduction of the limb keeps the head of the bone in contact 
with the dorsal surface of the ilium. Circumduction and 
rotation outward causes the head of the bone to glide over 
the border of the acetabulum into the socket. 

If, in any case, the opening in the capsule is too small to 
permit return of the head of the bone it may be enlarged, 
as suggested by Prof. Bigelow, by circumduction of the 
flexed thigh across the abdomen '' in a direction opposite to 
that in which it is desired to lead the head of the bone, 
which should be made in this way to pass across below the 
socket, and never above it, across the Y -ligament." The 
subcutaneous rupture of the Y^lig'^^^^nt is an injury of not 
much importance when the advantages gained are considered. 
The strength of the Y'lig^'^^^t permits this rupture to 
take place, " it being strong enough to rupture the whole of 



DISLOCATIONS. 



435 



Fiff. 208. 



the rest of tlie capsule and the obturator muscle, without it- 
self yielding." Tliis laceration of the capsule by circum- 
duction of tlie tliigh is performed instead of the operation 
suggested by Dr. Keid, of enlarging the capsule by incision 
in case the opening is too small to permit return of the head 
of the bone. 

Ischiatic or sciatic dislocations may be reduced by the 
same manipulations as iliac, namely, flexion, abduction, and 
rotation outward. The difficulty sometimes encountered in 
effecting reduction in this variety by extension, is due to the 
position of the tendon of the obturator internus muscle and 
capsule between the head of the femur and the acetabulum. 
Flexion and circumduction inward relaxes the tension of the 
muscle and permits the head 
to be lifted easily into place. 
Care should be observed in 
making abduction in these vari- 
eties not to employ too much 
force lest the capsular ligament 
be unduly torn and permit the 
bone to pass m front of the ace- 
tabulum. 

In the thyroid dislocation 
the manipulations are in part 
the reverse of those executed 
in effecting reduction in the 
dorsal displacements. Flex the 
limb at a right angle to the 
pelvis, abduct it slightly and 
rotate the thigh strongly in- 
ward, adduct it and bring the limb in this position to the 
floor (Fig. 208). Reduction may also be accomplished by 




436 DISLOCATIONS. 

flexing the thigh, phicing the foot on the inside of the groin 
and making lateral traction. Or the thigh may be drawn 
outward by a towel placed round the upper part, while lateral 
traction is made. 

Pahic dislocation may be reduced by the same methods of 
manipulation as those employed in the thyroid variety. The 
position of the head of the bone upon the ramus of the 
pubes requires that the flexion of the thigh should be as 
complete as possible, in order to dislodge the bone from its 
abnormal situation, then it should be rotated internally and 
adducted, and in this position brought to its place. Another 
method may be employed by which the head of the bone may 
be pressed into place, while the limb is flexed and abducted. 

Reduction of the iliac, sciatic, and thyroid varieties of dis- 
location have been etfected by placing a well-padded piece of 
wood, as a fulcrum, as employed by the late Dr. Brainard, 
of Chicago, or a cylinder of cloth, as used by Dr. George 
Sutton, of Indiana, in the perineum, the limb being used as 
a lever to lift the head of the femur over the border of the 
acetabulum. 

Reduction hy Extension. — This method is employed by 
pulleys in the same manner as described in connection with 
shoulder-joint luxations. 

Extension may be made in tlie vertical or longitudinal di- 
rection. The perfection to which the methods of manipula- 
tion have been brought, and their employment in accordance 
with well-established anatomical principles, have enabled the 
surgeon to depend almost entirely upon them in accomplish- 
ing reduction in recent hip-joint dislocations. Extension 
with the pulleys may be needed in old dislocations, when it 
should be employed with the greatest care, in order to avoid 
the infliction of injury upon the parts. The pulleys should 



DISLOCATIONS. 



437 



be attached to the limb, as shown in Fig. 209. Tlie traction 
should be made slowly, gently, and gradually until the head 

Fig. 209. 




of the bone reaches the margin of the acetabulum, when the 
surgeon, the traction being maintained, should grasp the leg 
and° rotate the limb in a direction opposite to the displace- 
ment, in order to bring it into the articulating cavity. In 
posterior dislocations the limb should be adducted and the 
extension made in a line with the limb in this position (Fig. 
209). In anterior displacements the limb should be ab 
ducted (Fi 



210), or the head forced out, as shown in Fisr. 



Fi2. 210. 




37* 



438 



DISLOCATIONS. 



211._ In employing vertical traction by the apparatus of 
Prof. Bigelow, rotation and elevation can be readily effected 
by the transverse and longitudinal rods attached to the splint 
(Fig. 212). 

Evidence of the return of the head of the bone to its artic- 
ulating cavity is sometimes afforded by a distinct " snap." 
Positive evidence is obtained in the complete restoration of 

Fm. 211. Fiff. 212. 




the movements of the limb, as flexion, extension, abduction, 
adduction, and rotation — in the re-establisment of the normal 
leno-th and position of the limb as compared with its fellow, 
and ascertained by measurements. 



DISLOCATIONS. 439 

The after treatment consists in rest in bed for ten days 
or two weeks, with the limbs fastened together at the knees, 
a compress being placed between them; at the end of a week 
passive movements may be carefully instituted to prevent 
stiffness or possible anchylosis of the articulation. The pa- 
tient should walk with the aid of crutches for two or more 
weeks, and then with a cane to afford support to the injured 
limb. After four or five weeks the reparative process is 
generally complete. 

Anomalous Dislocations As a result of extraordinary 

violence it sometimes happens that the head of the femur is 
forced into positions differing somewhat from those described 
as the usual or reorular forms. These are desi<2^nated anoma- 
lous dislocations, and when they occur, the bone may be 
placed above the margin of the acetabulum, between the 
anterior superior and inferior spinous processes of the 
ilium, below the border of the acetabulum, on the body 
and tuberosity of the ischium, in the perineum behind the 
scrotum, or under the arch of the pubes. The symptoms 
are usually so characteristic as to lead to a correct diagnosis 
as to the nature of the luxation. The treatment is conducted 
by manipulation, as in the ordinary forms, or by pulleys, if 
necessary. Reduction may be sometimes facilitated ' by 
changing the displacement of the bone into that of one of 
the regular forms, and employing the usual methods to ac- 
complish replacement. 

Incomplete Dislocations Much discussion has taken 

place with regard to the possibility of the occurrence of 
partial or incomplete luxations of the hip-joint. It is gene- 
rally believed that the construction of the articulation will 
not permit, in the strictest sense, this form of displacement 
as the result of traumatism. Cases in which it has been 



440 DISLOCATIONS. 

reported in medical journals as having occurred, have been 
recorded by Malgaigne, Hamilton, and Warren. 

Subluxation of the joint sometimes occurs in persons of 
feeble habit in whom relaxation and elongation of the 
muscular and ligamentous tissues exist. Acrobats, who de- 
velop the muscular and ligamentous system to the fullest 
extent in their peculiar vocations, are frequently able to 
produce, at will, dislocation of this joint as well as of most 
of the freely movable articulations. Where it is desirable, 
mechanical support may be afforded by belts or bandages. 

Complications of Hip-joint Luxations. — In discussing 
the prognosis of dislocations of the hip-joint allusion has 
been made to the occurrence of complications, as fracture of 
the femur or of the acetabulum, or laceration of the sciatic 
nerve. In fracture of the femur, taking place as a complica- 
tion of dislocations, the broken bone should be dressed tem- 
porarily with short splints and bandages to give it requisite 
firmness while the limb is used as a lever in reducing the 
luxation, afterwards permanent dressings should be applied 
and the injury treated as in ordinary cases. In fracture of 
the acetabulum, extension by weights and pulley should be 
made after reduction, in order to retain the bone in place 
until repair has occurred. Laceration of the sciatic nerve 
should be treated by keeping the parts at rest and institut- 
ing, at the expiration of two or three weeks, passive move- 
ments with frictions, and, if required, applications of elec- 
tricity. 

Old Dislocations In view of the dangers which some- 
times attend efforts at reduction in cases of old dislocations 
of the hip-joint, the propositions, stated on page 370 with re- 
gard to the conditions which should govern interference in old 
luxations of the shoulder-joint, may be, in general, accepted 



DISLOCATIONS. 441 

in tlieir application to chronic hip-joint luxations. The 
correction of the disability which accompanies unreduced 
hip-joint dislocations is, if anything, more important than in 
similar conditions in the shoulder-joint on account of the 
interference with locomotion, hence very careful considera- 
tion should be given to each case with the view, if possible, 
of affording relief. While the period of eight weeks, as fixed 
by Sir Astley Cooper, after which it is regarded imprudent to 
make efforts at reduction, is generally accepted by surgeons 
as correct, there are a number of instances on record in 
w^hich reduction has been accomplished at periods ranging 
from six months to five years. The character of the dislo- 
cation wnll influence, to some extent, the propriety of inter- 
ference and chances of success, as experience has shown 
that luxations of the iliac and puhic varieties yield much 
more readily than those of the sciatic and thyroid. In the 
latter, the head of the bone becomes immovably fixed at a 
much sooner period of time than in the former. Immo- 
bility of the head of the bone may be regarded as indicating 
the existence of firm adhesions which would seriously inter- 
fere with any attempts at reduction. It would also indicate 
the occurrence probably of severe inflammation subsequent 
to the receipt of the injury, which might cause changes in 
the condition of tiie acetabulum which would render the 
return of the head of the bone impracticable. The oblitera- 
tion of the acetabulum, partial or complete, occurs more 
rapidly in the young than in the old. Sometimes no changes 
occur in the cavity, after dislocation, as in the dissection re- 
corded by Fournier, where luxation had existed for thirteen 
years. Information might be gained as to the condition of 
the cavity by introduction and exploration with the explor- 
ing needle. The amount of disability present should guide 



442 DISLOCATIONS. 

the surgeon in his decision with regard to interference ; if a 
new joint has been formed which but slightly abridges the 
movements of the limb, it would be desirable not to interfere 
with it, lest injury should be inflicted upon the parts by the 
efforts made, without success, in accomplishing reduction 
and a full restoration of the function of the limb. A feeble 
state of health or advanced age would contraindicate the 
employment of efforts at reduction, on account of the shock 
produced by the violence and the inflammation liable to 
supervene. 

Cases have been reported in which abscesses of very ex- 
tensive character have formed after the movements made in 
endeavoring to effect reduction. In such cases the treat- 
ment should consist in free incisions and the introduction of 
tubes to secure free drainage. 

When it is decided to make efforts at reduction, the pa- 
tient should be subjected to preliminary treatment by gentle 
movements of the limb in order to sever the adhesions, and 
absorption of the plastic deposits should be promoted by the 
administration of small doses of mercury. Reduction should 
be attempted by manipulation, and if this failed, resort 
should be had to extension by the pulleys, made in the man- 
ner suggested by Prof. Bigelow, or in the longitudinal direc- 
tion. The angular extension is adapted best for dorsal lux- 
ations. In the efforts made by manipulation the neck of the 
femur is sometimes broken, an accident which is generally 
followed by good results, as far as relates to the correction 
of the deformity and the restoration of the function of 
the limb by the establishment of a false joint. In cases in 
which reduction cannot be effected and where the disability 
is great, an artificial joint should be formed by subcutaneous 



DISLOCATIONS. 443 

section of the neck of the bone, as performed in the surgical 
neck of the liumerus in old shoulder-joint luxations. 

Congenital Dislocations. — A number of cases of congeni- 
tal dislocation of the hip-joint have been carefully examined 
and recorded. The structural deficiencies involve the ace- 
tabulum, head and neck of the femur and ligaments of the 
articulation, showing partial or complete obliteration of the 
first, atro[)hy and distortion of the second, and elongation 
and relaxation of the third, with sometimes an entire ab- 
sence of the teres ligament. It may occur as a bilateral or 
unilateral condition, the number of cases being about equally 
divided ; females are affected more frequently than males. 
The varieties of the dislocation are usually the iliac^ thyroid^ 
and pubic. The affection is not usually detected until efforts 
at walking are made by the child, when the symptoms are 
found to be quite characteristic and easily recognized. The 
elongation of the ligaments and the absence of the firm sup- 
port of the acetabulum and head and neck of the femur per- 
mit the pelvis to descend between the thighs giving rise to 
a peculiar gait. In the recumbent position the limbs can be 
lengthened or shortened without causing pain to the child. 
In the great majority of cases the treatment can only be 
palliative, support being afforded by strong bands or belts 
fastened around the pelvis so as to hold the thigh bones against 
it. Subcutaneous section of the muscles inserted into the 
great trochanter has been performed by Mr. Brodhurst, of 
London, with benefit to the patient. 

Patella — The anatomical relations of the patella have 
been fully discussed on page 259 in connection with frac- 
tures of the bone. 

Dislocations of the patella may occur in the outward 
(Fig. 213), inward (Fig. 214), upward., downward., and 



444 



DISLOCATIONS. 



vertical direction. In complete displacements, the tendinous 
structures of tlie quadriceps extensor femoris muscle are 



Fi?. 214. 





lacerated, to a greater or less extent, as well as the synovial 
membrane of the knee-joint. 

Causes Dislocations of tlie patella are caused by direct 

violence and muscular action, the hitter being tlie most fre- 
quent cause. The influence of muscular action is exerted 
in dancing or leaping, or in sudden twists of the leg;, the 
thigh being extended and tixed. The bone may be dis- 
placed by blows, forcing it outward or inward. In persons 
in whom a relaxation of the ligamentous tissues exists, luxa- 
tion may be easily produced by muscular action combined 
with a slight rotation of tlie leg. 

Symptoms — In the incomplete displacement tlie inner 
articulating surface of tlie patella rests upon the articulating 



DISLOCATIONS. 445 

surface of the external condyle, the inner edge lying in tlie 
intercondyloid groove. The displaced bone in its abnormal 
situation increases the breadth of the knee, forming a 
prominence over the external condyle, which may be felt 
and the edges of the bone distinguished. A marked 
depression exists over the front of the knee. The limb is 
fixed in the extended position, efforts at flexion causing 
great pain. In the complete outward dislocation the bone 
rests in an oblique position upon the anterior and outer sur- 
face of the external condyle, the anterior ligament and 
synovial membrane being ruptured. 

In the inward luxation, a rare form of displacement, the 
conditions are reversed. In the complete variety the patella 
is forced beyond the internal condyle, the edges directed 
antero-posteriorly,and thearticulatingsurfaces restingagainst 
the outer surface of the condyle. The internal surface of 
the joint is rendered prominent, and the knee is increased in 
width. 

The vertical dislocation is also of very rare occurrence. 
In this form the bone is turned upon its edge, firmly fixed 
in the groove between the condyles behind and the tense 
integument in front. The symptoms are very marked. 
Pain is very intense and increased on slight efforts to mov^e 
the limb, which is fixed in a state of extension. The 
quadriceps extensor femoris muscle is tense. The bone can 
be readily felt in its position. A few instances have been 
reported in which the patella has been completely turned 
over, the articulating surface being placed anteriorly. 

The upward dislocation may occur as tlie result of patho- 
logical changes in the knee-joint or of rupture of the liga- 
mentum patellce. In the former the displacement is gradual, 
in tlic latter sudden. The elevation of the bone makes a 
38 



446 DISLOCATIONS. 

prominence above the condyles and leaves a marked de- 
pression over the front of the knee-joint. 

In the downward luxation a rupture of the extensor 
muscle occurs at the point of its attachment to the upper 
border of the patella, leaving a depression between two 
prominences, that above formed by the torn tendon of the 
muscle and that below by the patella. The functions of the 
limb are impaired and the knee-joint is swollen and painful. 

Diagnosis Examination of the parts before much 

swelling lias occurred w^ill enable the surgeon to detect the 
nature of the dislocation in the various forms described. 
The upward luxation is to be distinguished from fracture 
by the intact condition of the patella and the presence of the 
depression below the prominence and not between two 
portions of it. 

Prognosis. — The prognosis is favorable as to reduction 
and restoration of the functions of the part. In some cases 
difficulty is experienced in effecting reduction in the vertical 
dislocation. In one instance severe inflammation of the 
knee-joint followed section of the ligamentum patellae and 
quadriceps extensor muscle made in order to promote 
reduction, causing ultimately the death of the patient by 
profuse suppuration and hectic. 

Treatment In the outward and in-ward dislocations the 

reduction may be easily effected by placing the patient in 
bed in the recumbent position, while the surgeon sitting on 
the edge places the heel of the injured limb on his shoulder, in 
this way relaxing completely the quadriceps extensor femoris 
muscle. With the thumb and fingers the patella is pressed 
into place. In the vertical luxation great difficulty is often 
experienced in obtaining reduction owing to the impaction 
of the bone in the intercondyloid groove, and the locking of 



DISLOCATIONS. 447 

the anterior edge in a slit of the fibrous expansion of tlie 
extensor tendon covering the surface of the bone, as suggested 
by Prof. Agnew. In effecting reduction the patient should 
be placed under the influence of an anaisthetic, and extreme 
flexion of the thigh upon the pelvis produced. An assistant 
should now alternately flex and extend the leg, while the 
surgeon places his thumbs on opposite sides of the bone, one 
below and one above, and makes firm pressure in opposite 
directions, in this way endeavoring to turn the bone over 
into place. 

Section of the muscle and ligament of the pat«lla should 
not be resorted to, owing to its want of value as a surgical 
procedure and the danger of provoking severe inflammation 
of the knee-joint. Spontaneous reduction has occurred in 
cases which have resisted manipulative efforts. 

The upward and downward dislocation should be treated 
in the same manner as fracture of the patella. 

Congenital dislocations of the patella have been observed 
in a number of instances. 

Tibia — Knee joint — Ginglymoid Articulation 

This articulation is one of the most perfect in the body, and 
is formed by the condyles of the femur above, the head of 
the tibia below, and the patella in front. The femur and 
the tibia are united by strong ligaments placed both with- 
out and within the joint. These ligaments are the anterior, 
posterior, internal, and two external lateral, connected by a 
thin, but strong intervening fibrous membrane, which is 
attached above to the lemur, to the upper border and sides of 
the patella, and to the head of the tibia and interarticular 
cartilages. Within the articulation are the two crucial or 
interosseous ligaments, the anterior or external, and the 
posterior or internal, attached below, in front and behind 



448 DISLOCATIONS. 

the spine of the tibia and to the semi-lunar fibro-cartilages, 
and above to the inner surface of the external and internal 
condyles of the femur. The external and internal semi- 
lunar fibro-cartilages are placed in the concave surfaces on 
the head of the tibia, being fastened to the bone by the 
coronary ligaments and to each other by the transverse liga- 
ment. The synovial membrane is the largest and most 
extensive in the body, covering completely the interior of 
the joint and the structures within it, and forming pro- 
longations which have been designated as the ligamentum 
mucosum and the ligamenta alaria. The knee-joint is not 
a true ginglymoid articulation, possessing as it does, in 
addition to flexion and extension, slight rotation, internal 
and external, the latter most extensive when the knee is 
semi-flexed. The intimate relations of the popliteal vessels 
and nerves to the posterior surface of the joint render them 
liable to injury in cases of posterior displacements. Owing 
to the very secure manner in which the bones of the knee-joint 
are held together by the arrangement of external and 
internal ligaments, and the support derived on all sides from 
powerful muscular and tendinous structures, dislocations are 
comparatively of infrequent occurrence. They may occur 
in the forward, backward, outward, and inward directions. 
In all forms there is rupture more or less extensive of the 
ligaments of tlie joint, associated, in some cases, with lacer- 
ation of the muscular structures. The dislocation may be 
complete or incomplete. 

Causes The causes of dislocations of the knee-joint may 

be traumatic or pathological. Traumatic displacements are 
due to violence applied either directly, as in blows upon the 
thigh or leg, or indirectly, as in falls upon the foot, when the 
limb is partially flexed or rotated. Lateral luxations are 



DISLOCATIONS. 



449 



Fis. 215. 



caused by direct force applied simultaneously to the tliio-h 
and leg in opposite directions, as in tiie passage of the wheel 
ofa wagon over the thigh, the leg being firmly fixed. In 
pathological dislocations of the knee-joint the destruction of 
the joint structures permits the muscles to draw the tibia up 
behind the femur producing the backward luxation. 

Si/mptof)is — The symptoms of the various forms of knee- 
joint dislocations are very prominent; pain, and immobility, 
with deformity, are present, the latter distinguishing the 
different forms. 

In the forward luxation the tibia is placed, in the com- 
plete variety, upon the anterior surface of the condyles of 
the femur (Fig. 215) ; in the par- 
tial form, the spine of the tibia rests 
in the intercondyloid groove. The 
forcible and wide separation of the 
articulating surfaces causes rupture 
of the capsular and anterior crucial 
ligaments and laceration, partial or 
complete, of the points of origin of 
the gastrocnemius and tendon of the 
biceps muscles. The head of the 
tendon in front, and the condyles of 
the femur behind, can be readily felt 
and distinguished in their abnormal 
positions. The limb is shortened 
from an inch and a half to two and 
a half or three inches, flexed or 
extended, and the leg is twisted, 

being rotated either outward or inward. The quadriceps 
extensor femoris muscle is relaxed, and the patella rests 

38=*= 




450 



DISLOCATIONS. 



either upon the head of the tibia or in a marked depression 
between it and the femur, out of which it can be lifted. 

In the backward luxation, the complete and incomplete 
form of which occur in about equal proportion, the position 
of the tibia is reversed from that occupied in the forward 
variety. (Fig. 216.) It can be felt in the popliteal space, 
where it rests beneath the popliteus muscle, which, with the 
gastrocnemius muscle and popliteal vessels and nerves are 
tightly stretched over it; the posterior ligament, and in some 
instances the muscles and popliteal artery, are ruptured. 
The shortening of the limb is less than in the forward va- 
riety and it may be either extended or flexed. The tendon 
of the quadriceps muscle with the pa- 
Fig. 216. tella is strongly stretched over the de- 
pression between the condyles of the 
femur and the tibia. 

The lateral dislocations of tlie knee- 
joint rarely occur in the complete form. 
They are attended usually by severe 
injuries to the structures of the joint, 
the lateral, and frequently, the crucial 
liojaments bein^ torn. 

In the outward dislocation the ex- 
ternal condyle of the femur rests either 
upon the spine of the tibia or upon one 
or the otlier side of it. (Fig. 217.) 
The joint is increased greatly in width, 
and a prominence exists upon the ex- 
ternal surface, formed by the external tuberosity and part of 
the head of the tibia, and one upon the internal surface 
caused by the internal condyle of the femur. The tendon of 
the quadriceps extensor is relaxed and the patella is displaced 




DISLOCATIONS. 



451 



externally leavinj^ a depression over the joint. The leg is 
flexed and rotated on its axis. 

The inward luxation is characterized by symptoms which 
are the reverse of those attending the outward displacement. 
The head of the tibia is displaced inwardly, so that the 
internal condyle rests on the spine of the bone or upon 
either side of it. (Fig. 218.) The joint is increased in 



Fig. 217. 



Fig. 218. 





width, the patella displaced internally, the leg flexed and 
twisted on its axis. The length of the limb is normal as in 
the outward variety. 

Diagnosis. — When an examination is made before the 
supervention of much swelling, the displaced condyles of the 
femur and head of the tibia can be readily outlined, and the 
nature of the dislocation determined in all of the varieties. 
The shortening of the limb will distinguish ihe forward and 



452 DISLOCATIONS. 

hachward dislocations from the lateral, in which the length 
is normal. 

Prognosis The very severe injuries inflicted upon the 

sensitive structures of the joint, especially the extensive 
synovial membrane, in some forms of dislocation which is 
liable to be followed by a high grade of inflammation, 
renders the prognosis doubtful as to the subsequent full 
restoration of the functions of the joint. More or less 
weakness is likely to exist for a long time following the 
accident. In backward dislocations complete rupture or 
laceration of the inner coats of the popliteal artery may 
occur, leading in the one instance to extensive infiltration of 
blood into the popliteal space, and, possibly, gangrene of the 
leg, and in the other to the formation of an aneurism. The 
nerve trunks are very rarely injured. 

Treatment In the complete variety of the, forward and 

backward dislocations, reduction may be effected by placing 
the patient in the recumbent position upon a firm mattress 
on the bed, administering an anaesthetic and obtaining 
counter-extension by a band secured to the thigh and held 
by an assistant, while extension is made by an another as- 
sistant who grasps the leg ; while firm and steady extension 
is made, the surgeon places his knee or forearm behind the 
joint and forcibly flexes the leg, in this way returning the 
tibia into place. In the incomplete luxation the surgeon 
may accomplish reduction by grasping the leg above the 
ankle, and, hooking the other arm under the knee, flexing 
the leg forcibly. 

In the lateral displacements, outward and inward, reduc- 
tion can be easily accomplished by making extension and 
counter-extension and pressing the luxated tibia into place. 
The severe inflammation which usually accompanies 



DISLOCATIONS. 453 

knee-joint dislocations requires confinement of the patient 
in bed after reduction, for three or four weeks, and tlie em- 
ployment of such remedies, internally and locally, as will 
control the morbid action. The limb should be placed in a 
long fracture box, with the knee slightly flexed and well 
supported, and dry or moist cold, by means of ice bags or 
irrigation with ice-water, or cold solutions of laudanum and 
lead-water should be applied over the joint. If necessary 
local depletion may be obtained by leeches, and mercurial 
purgatives may be administered. Pain should be allayed 
by anodynes. When the inflammation has subsided and 
the reparative process has sufficiently progressed, at the ex- 
piration usually of two and a half to three weeks, gentle 
mevements should be made to prevent anchylosis. After 
release from bed the patient should walk with the aid of 
crutches, placing no weight upon the injured limb until two 
months have elapsed since the receipt of the injury. Sup- 
port should be afforded to the joint by an elastic cap and 
friction should be made wath stimulating liniments. 

Complicated dislocations of the knee-joint are very grave 
accidents. The complications may consist in fracture of the 
tuberosities or head of the tibia, or rupture of the popliteal 
artery. In fracture, replacement of the fragment may occur 
in effecting reduction of the dislocation. If this does not 
occur it should be pressed into place after return of the dis- 
placed tibia. The treatment should be that advised in frac- 
tures involving the knee-joint on page 257. Rupture of the 
popliteal artery, the existence of which is recognized by the 
sudden occurrence of swelling in the popliteal space, with 
cessation of pulsation in the tibial arteries and coldness of 
the leg, demands immediate amputation. 

Compound dislocations of the knee-joint require in their 



454 DISLOCATIONS. 

treatment the most careful consideration and the exercise of 
the best judgment on the part of the surgeon. In cases in 
which the joint is extensively laid open, and the tissues 
greatly lacerated, amputation is the proper treatment. Where 
the injury is less severe, and the patient young and in robust 
health, excision may be performed, and the joint treated by 
strict antiseptic methods. The danger to which the patient 
is exposed, in the attempt to save the limb, is the occurrence 
of tetanus, pyaemia, or exhaustion from prolonged suppura- 
tion. 

Congenital dislocations of the knee-joint have been from 
time to time observed. They occur in connection with one 
or both knees, and most frequently in the forward direction. 
Successful results in a number of cases have been obtained 
by the application of splints and bandages after reduction. 
In others, tenotomy of the tendons of the muscles involved 
has been effectual in preventing recurrence of tlie displace- 
ment after reduction. 

Semilunar Cartilages. — As stated in connection with 
the description of the ligaments of the knee-joint, the semi- 
lunar cartilages are secured in place by the coronary liga- 
ments to the head of the tibia and to each other by the 
transverse ligament, their extremities being firmly implanted 
in the depressions in front and behind the spine of the tibia. 
The external cartilage differs from the internal, in that it 
forms more of a circle, covering to a large extent the ex- 
ternal articular surface of the head of the tibia, and is attached 
to the anterior and posterior crucial ligaments by its ex- 
tremities. In the movements of the joint they glide back- 
ward and forward with the tibia during flexion and exten- 
sion. In dislocation of one of the cartilages the coronary 
ligaments are ruptured, permitting it to remain fixed during 



DISLOCATIONS. 4o5 

movements of the tibia, and in this way it becomes impacted 
between the articulating surfaces of the condyle of the femur 
and the head of the tibia. The internal cartilage is the one 
most frequently displaced, an occurrence possibly due to its 
less firm attachments. The accident occurs usually in per- 
sons of delicate health, and is caused by a sudden and for- 
cible twist of the joint or slip of the foot with rotation in- 
ward of the leg, the thigh at the time being fixed or rotated 
outward. 

Tlie symptoms are very characteristic, the occurrence of 
the displacement being attended with a sudden faintness, 
intense pain in the joint, and an inability to stand or walk. 
The pressure upon the displaced cartilage causes intense 
pain and shock ; swelling soon appears, indicating the col- 
lection of fluid in the joint due to pressure and the acces- 
sion of inflammation of tlie synovial membrane. 

The diagnosis is made by careful examination of the 
joint and inquiry as to the manner in which the injury was 
received. The sudden occurrence of faintness, pain, and im- 
pairment of the functions of the joint will direct attention to 
the nature of the displacement. 

The prognosis is favorable, reduction being usually easily 
accomplished and the functions of the joint unimpaired. In 
most cases there remains a tendency to recurrence of the 
displacement, which may be overcome by the exercise of 
caution on the part of the patient, in the execution of strong 
and sudden flexion of the knee. 

The treatment consists in reducing the displaced cartilage 
and supporting the joint for some time with a bandage or 
elastic cap. In accomplishing reduction the patient should 
be placed in the recumbent position, and an anagsthetic ad- 
ministered. The surgeon having flexed the thigh upon the 



45G DISLOCATIONS. 

pelvis should grasp tlie leg above the ankle, and, hooking 
the other arm under the knee-joint, make sudden and forci- 
ble flexion, and then full extension, with rotation, of the 
leg. 

Tibia and Fibula — Superior Tibio-fibular Ar- 
ticulation — Arthrodial Articulation This joint is 

formed by the flat oval surface on the external tuberosity of 
the tibia and a similar facet upon the head of the fibula, 
connected by the anterior and posterior superior tibio-fibular 
ligaments. A synovial membrane, which is sometimes con- 
tinuous with that of the knee-joint, covers the interior of the 
joint. The movements of the articulation are limited to a 
slight gliding of the surfaces one upon the other. Disloca- 
tion of the joint is very rare ; it may occur either in the for- 
ward or backward direction, more frequently in the former 
than in the latter. 

Causes. — The causes of dislocation are direct or indirect 
violence and muscular action. 

Symptoms The principal symptom is deformity, which 

is caused by the displacement of the bone e.\i\\ev forward or 
backward. If the luxation is very complete some disability 
may be present. 

Diagnosis The superficial position of the articulation 

permits of its easy examination, its abnormal mobility being 
readily detected by grasping the head of the bone. 

Prognosis. — Sometimes difficulty may be experienced in 
securing permanent retention of the head of the bone owing 
to the shallow character of the articular surfaces. 

Treatment. — Reduction may be accomplished by flexing 
the leg, so as to relax the biceps muscle Avhich is inserted 
into the head of the fibula, and press the bone into place, 
where it may be retained by the application of adhesive 



DISLOCATIONS. 457 

Strips and the maintenance of the limb in the Hexed posi- 
tion for three or four weeks until union of the ligaments 
occurs. A [)laster or silicate bandage may be applied to the 
foot and leg, carrying it to the middle of the thigh so as to 
immobolize the limb and keep the displaced bone in place. 

Subluxati07i, occurring in persons of feeble health, and due 
to a relaxed condition of the ligaments, should be treated by 
the administration of tonics, and the repeated applications of 
counter-irritants, as tincture of iodine, or vesication with 
small blisters. In some cases it may be necessary to excite 
inflammatory action in and about the articulation by scarifi- 
cations made with a delicate tenotome introduced subcuta- 
neously. 

Inferior Tibio-fibular Articulation — Arthro- 

DiAL Articulation The tibia and fibula enter into the 

formation of this joint by rough triangular convex facets on 
the outer and inner surfaces respectively of their lower ends. 
They are united by the interosseous, anterior and posterior 
inferior tibio-fibular, with the transverse ligaments, the syn- 
ovial membrane being derived from the ankle-joint. Very 
slight gliding of the surfaces upon each other is the only 
movement permitted in this articulation. Dislocation of 
the joint, as an independent lesion, is a very rare occurrence, 
and when it occurs, it is in the backward direction. One case 
is recorded by Boyer in which simultaneous dislocation of 
both superior and inferior articulations occurred. 

The cause of displacement at this joint is great violence 
directly applied, as may happen in falls, from a height, upon 
the foot. 

The symptoms are pain, deformity, and loss of function. 
Swelling is liable to follow soon upon receipt of the injury. 

The diagnosis is made by careful examination of the 
39 



458 DISLOCATIONS. 

part, by which the position of the displaced bone may be 
determined, providing much swelling has not occurred. 

Treatment. — Replacement of the dislocated fibula may be 
accomplished by extending the leg so as to relax the pero- 
neus longus and brevis muscles which run in a groove on 
the posterior border of the bone and pressing the end for- 
ward into place. A figure-of-8 bandage of the leg and foot 
should be applied, and the limb should be kept quiet in a 
fracture-box for a period of three or four weeks. Passive 
motion and frictions should be employed to overcome stiff- 
ness of the ankle-joint. 

Tibia, Fibula, and Astragalus — Anele.-joint — 
GiNGLTMOiD Articulation. — The ankle-joint is formed 
by the lower end of the tibia and the internal malleolus, the 
external malleolus of the fibula, and the upper convex sur- 
face of the astragalus witli its two lateral facets. The union 
of the articular surfaces of the tibia and fibula forms an arch 
in which the astragalus is received. The ligaments are the 
internal and external lateral, with a thin membranous layer 
in front called the anterior ligament. A similar layer is 
placed posteriorly, forming with the other ligaments an im- 
perfect capsule of the joint. The synovial membrane lines 
the interior of the joint. The ankle is a true hinge-joint, 
possessing flexion and extension without lateral movement. 
In dislocation of the ankle-joint the foot is displaced ante- 
riorly, forming the forward^ posteriorly, the backward., and 
laterally, the outward and inward varieties of dislocation. 
The great strength of this joint makes dislocation a rare 
occurrence. 

Causes — Luxations of the ankle-joint are the result of 
great violence applied directly, as blows upon the front of 
the leg, producing forward displacement of the foot or a 



DISLOCATIONS. 



459 



Fifr. 219. 



fall upon tlie heel, the leg being fixed, the foot strongly 
flexed ; blows upon the back of the leg, the foot being fixed 
will project the tibia and fibula forward, producing a back- 
ward displacement of the foot. Lateral dislocations are 
caused by force indirectly applied, as in falls upon either side 
of the foot, producing violent abduction or adduction. 

Symptotns The chief symptom of dislocation of the ankle- 
joint is deformity caused by the displacement of the foot. 

In the Gom^^lQi^ forward luxation the ligaments are torn 
and the astragalus 
rests in front of the 
tibia forming a dis- 
tinct prominence. 
(Fig. 219.) In 
the incomplete va- 
riety, the astraga- 
lus is but slightly 
separated from the 
articulation. The 
foot is lengthened 
and the heel mark- 
edly shortened. The 
tendo Achillis lies 
close in contact 
with the posterior 
surface of the tibia; 
the function of the 
foot is impaired, 
especially as re- 
gards flexion. In 
/jar/m/luxation the 
symptoms are much 
less prominent. 




Fis. 220. 




460 DISLOCATIONS. 

The complete backward dislocation of the ankle-joint, in 
addition to the rupture of all of the ligaments, is frequently 
accompanied by fracture of the fibula and in some instances 
by fracture of both tibia and fibula. The tibia and fibula 
rest upon the scaphoid and cuboid bones in the complete 
luxation (Fig. 220); in the incomplete form, the tibia rests 
upon the head of the astragalus and the fibula upon the greater 
process of the os calcis. The symptoms of the backward 
displacement are shortening of the foot with lengthening and 
elevation of the heel. The tendo Achillis is removed from 
the posterior surface of the leg, and is very prominent. Tlie 
toes are flexed, and the tibia can be readily felt in its abnormal 
situation. 

In the outward dislocation the internal lateral ligament 
is ruptured, and in some instances the internal malleolus. 
The pressure exerted upon the external malleolus at the time 
of dislocation is frequently sufficient to fracture the fibula 
some distance above, producing that form known as Pott's 
fracture. (Fig. 221.) The deformity is characteristic ; 
the internal malleolus is very prominent and the foot rests 
upon the inner surface in a state of marked eversion. (Fig. 
222.) The point of fracture of the fibula can be distinguished 
by the depression above the external malleolus and by the 
crepitus, which can be elicited on making movements of 
adduction and abduction. 

In the inward luxation the external lateral ligament is 
torn and the foot is inverted, resting upon the outer border. 
The external malleolus can be felt as it projects beneath the 
tissues ; fracture of the fibula frequently accompanies this 
form of dislocation. 

Dislocation upivard, in which variety the astragalus is 
forced upward between the tibia and fibula, is a very rare 



DISLOCATIONS. 



461 



accident. In one form of this luxation the fibula is fractured 
and widely separated from the tibia. The projection down- 



Fig. 221. 




Fig. 222. 



:^^\^ 




ward of both malleoli, sometimes reaching to the sole of the 
foot, with the great increase in the breadth of the ankle and 
the separation of the tibia and fibula, constitute the symp- 
toms of this variety of ankle-joint dislocation. 

Diagnosis — The diagnosis in the various forms of dislo- 
cation of the ankle-joint is made by a careful examination of 
the parts. The displacemen in each variety is character- 
istic, and can be usually easily recognized on examination. 
Fracture, complicating the injury, can be distinguished by 
crepitus and mobility. In the uncomplicated dislocation 
immobility is a prominent symptom. 

39* 



462 DISLOCATIONS. 

Prognosis More or less weakness of the joint, which 

may disappear gradually, is liable to follow dislocation of 
the joint. Reduction and retention in the backward and 
inward luxation are sometimes difficult to accomplish. 

Treatment In the forward and backward dislocations 

the leg is flexed upon the thigh to relax the gastrocnemius 
muscle, and an assistant grasps the leg to make counter-ex- 
tension, while the surgeon seizes the foot, and draws it forward 
or presses it backward, making at the same time exten- 
sion or flexion, as the case may require. If much resistance is 
offered, it may be overcome by division of the tendo Achillis. 

In the lateral displacement, outward or inward^ extension 
and counter-extension should be made with abduction or 
adduction as maybe required to replace the bone. Pressure 
upon the astragalus will assist in the effort. An anaesthetic 
should be given if much resistance is offered. In the up- 
ward variety reduction is effected by extension and counter- 
extension. A bandage should be applied to the foot and leg 
to maintain the tibia and flbula in apposition, and the leg 
should be placed in a fracture box. 

Inflammation of a severe form is liable to occur after dis- 
location of the ankle-joint, which requires active treatment 
by local depletion, if necessary, and applications of lauda- 
num and lead- water. Immobilization in lateral splints or in 
fracture box should be accomplished, and passive motion 
should be instituted at the end of ten days to two weeks to 
prevent anchylosis. When the dislocation is complicated 
by fracture, the treatment should be conducted in accordance 
with directions given for fractures involving the ankle-joint. 

Compound dislocations are more frequent in occurrence at 
this articulation than at any other, and they are always 
attended by symptoms of great gravity. As a rule the 



DISLOCATIONS. 



4G3 



Fiff. 223. 




wound of the soft structures is caused by a protrusion of the 
internal malleolus. (Fig. 223.) 

The symptoms are unmistakable, and the diagnosis is 
easily made made by an examination of the parts. The 
'prognosis is doubtful, fa- 
tal results having fol- 
lowed in many cases re- 
ported, and disability in 
the event of recovery 
from the accident. 

The treatment consists, 
either in immediate am- 
putation or an attempt 
to save the foot, with 
or without excision of the 
malleolus. In this injury 
as in compound disloca- 
tion of the knee-joint, the most careful consideration on the 
part of the surgeon is demanded. While statistics show that 
formerly the best results followed immediate amputation, it 
is believed that the antiseptic methods of wound treatment 
now enable the surgeon to accomplish results equally good 
and with the preservation of the foot. If the injury is very 
severe, the tissues extensively lacerated, and the bones com- 
minuted, amputation should be performed. In cases of less 
severity, when the tibia protrudes through the wound, ex- 
cision should be performed and the wound treated antisep- 
tically. When the tibia does not protrude excision should 
not be practised. 

Tarsus — Tarsal Articulatioxs — Arthrodial and 

Enarthrodial Articulations The tarsal articulations 

are divided, as those of the carpus, into three sets ; first, that 



4G4 DISLOCATIONS. 

of the first row of tarsal bones ; second, those of the second 
row, and third, those of the two rows with each other. The 
first row, consisting of the os calcis and astragalus, is united 
by three ligaments, the external calcaneo-astragaloid^ the 
posterior calcaneo-astragaloid, and interosseous. The second 
row, composed of the scaphoid, cuboid, and three cuneiform 
bones, is connected by three ligaments, the dorsal, plantar, 
and four interosseous. The two rows are joined by three 
sets of ligaments, those between the os calcis and cuboid, 
four in number, two dorsal, the superior calcaneo-cuboid, 
and the inferior calcaneo-cuboid or interosseous, and two 
plantar, the /o?i^ and short calcaneo-cuboid; those between 
the OS calcis and scaphoid, two in number, the superior and 
inferior calcaneo-scaphoid, and that between the astragalus 
and scaplioid, the astragalo-scaphoid. Four synovial mem- 
branes are placed between the surfaces of adjacent tarsal 
bones and the second and third metatarsal, while the articu- 
lation between the internal cuneiform and first metatarsal 
and cuboid and fourth and fifth metatarsal bones, are lined 
by separate sacs. (Fig. 224.) 







DISLOCATIONS. 465 

A gliding movement from before backward, and from side 
to side, occurs between the os calcis and astragalus. A slight 
movement of the same character takes place between the 
scaphoid, cuboid, and cuneiform bones. The articulations 
between the astragalus and scaphoid, and os calcis and cuboid 
being enarthrodial in character, permit a degree of rotation, 
by means of which the sole of the foot may be slightly flexed 
or extended, or carried inward and outward. The secure 
manner in which the different bones of the tarsus are fastened 
together, and the astragalus to the bones of the leg, renders 
their separation, as an uncomplicated injury, a very rare oc- 
currence. Of the different bones of the tarsus, the astragalus, 
owing to its position and relations, is more liable to suffer 
from luxation than the others. Dislocations of the os calcis, 
scaphoid, cuboid, and cuneiform bones are extremely rare 
accidents, especially when they occur as uncomplicated 
luxations. 

Causes. — The bones of the tarsus require for their dislodg- 
meut the application of extreme force, as in falls from a 
height, the foot being violently twisted or turned. 

Astragalus Dislocations of the astragalus may occur 

in the forwcij'd, hachivard, and lateral directions. The dis- 
placement may be complete or incomplete. 

In the complete forward dislocation the astragalus is forced 
from its normal position and articulations, and placed in 
front of the tibia, upon the scaphoid, or as far forward as 
the cuneiform bones. In the incomplete variety the head of 
the bone may be separated from the articulation with the 
scaphoid and rest upon it. The degree of anterior displace- 
ment varies in the incomplete form. 

In the backward luxation the astragalus is dislodged from 



466 DISLOCATIONS. 

its articulation with the os calcis and scaphoid, and rests 
upon the superior surface of the posterior part of the os calcis. 

Lateral displacements of the astragalus can only occur 
when associated with fracture of either tibia and fibula or 
both. In such cases the astragalus will be displaced either 
to the inner or outer side, the separation of the bone from 
the OS calcis being usually incomplete. 

Symptoms In i\\Q forward luxation the principal symp- 
tom is the deformity, which is characteristic. The displaced 
bone forms a marked prominence in front of the ankle. The 
astragalus, as it passes forward from its normal position, is 
directed to the inside or outside ; as a result of this devia- 
tion, the foot is twisted or turned in the direction opposite 
to that taken by the bone ; when it is directed externally 
the foot is turned inward, and the external malleolus is made 
prominent ; internal deviation produces an eversion of the 
foot with prominence of the internal malleolus. 

In the backward dislocation a marked prominence exists 
over the heel ; the tendo Achillis is stretched over the pro- 
jection, and the gastrocnemius muscle is tense. Sometimes 
a depression can be felt in front of the tibia, and the foot ap- 
pears somewhat shortened. 

Diagnosis In the complete form of both the forward 

and backward dislocation the position of the displaced bone 
is so superficial that it can be easily outlined, and the nature 
of the dislocation determined. Some difficulty is experi- 
enced in detecting the degree of displacement in the incom- 
plete forms, the symptoms being usually obscure. 

Prognosis The difficulty attending successful reduction 

of the backward dislocation renders the prognosis unfavor- 
able with regard to that form. In a number of cases re- 



DISLOCATIONS. 407 

ported in which reduction was not effected, the functions of 
the foot were ultimately restored to a great extent. 

Treatment. — Owing to the twisted position assumed by 
the astragalus at the time of its displacement and the firm 
manner in wliich the bone is locked in its abnormal situation, 
reduction in the forward dislocation is often extremely 
difficult and in the backward form im[)0ssible, having been 
effected in this variety in but one case thus far reported, 
and in that, there .was associated with the dislocation 
fracture of both tibia and fibula which, without doubt, 
removed the rigidity of the parts and facilitated replacement. 
^Notwithstanding the unfavorable prognosis as to reduction 
in these cases, efforts should always be made, however, to 
effect it. It is of the utmost importance that the efforts 
should be made with great discretion lest untoward results 
attend them. Violent and prolonged attempts are liable to 
excite undue inflammation and cause sloughing of the 
tightly stretched integument overlying the displaced bone. 
If efforts made in the proper manner and for a suitable period 
of time are unavailing, subcutaneous section of resisting 
muscular and tendinous structures should be made with a 
view to facilitate replacement. Chief among these structures 
is the tendo Achillis, section of which may alone be efficient. 
If, even after the adoption of these measures reduction is 
not accomplished, the tension of the parts should be relieved 
by subcutaneous incisions to overcome the tendency to 
sloughing of the integument. In cases of comjdete dislo- 
cation of the bone where it lies loose beneath the integument 
and muscles of the dorsum of the foot, excision should be 
performed at once. The descent of the tibia upon the 
articulating surface of the os calcis renders the replacement 
in these cases impossible. 



468 DISLOCATIONS. 

In ihe^ forward dislocation reduction should be attempted 
by extension and counter-extension combined with pressure. 
The leg being flexed so as to relax the gastrocnemius mus- 
cle, the surgeon should grasp the instep and heel, and 
make extension with abduction and adduction as required, 
while an assistant makes counter-extension by seizing the 
leg and holding it firmly. Pressure may be exerted at the 
same time upon the bone to return it to its place. 

In the backward luxation eflforts should be made to effect 
replacement of the bone by extension and counter-extension 
as in the forward variety ; firm pressure should be made 
upon the displaced bone to endeavor to force it into its place. 
Section of the tendo Achillis may be made, if the attempts 
are unavailing. Caution should be observed in prolonging 
violent efforts owing to the danger of exciting undue infiam- 
mation. Experience has shown that the impairment of 
function is not very great in cases of unreduced backward 
dislocation, and that patients suffering from this condition 
have very useful limbs. In the lateral dislocation reduction 
is effected by extension and counter-extension. Opposite 
views are entertained by authors with regard to the propriety 
of excision in cases of irreducible dislocations of the 
astragalus. The- cases analyzed by Broca, as quoted by 
Prof. Gross, show very successful results following tlie oper- 
ation of excision ; forty-two terminating successfully out of 
fifty-two operated upon. Prof. Agnew advises that the bone 
should be permitted to remain undisturbed whatever may 
be its position. Excision should only be resorted to when 
ulceration of the soft parts occurs and the bone is exposed. 

Subastragoloid or Astragalo-Calcaneo-Scaphoid Dislo- 
cation In this rare form of displacement the astragalus is 

forced from its articulation with the os calcis and scaphoid. 



DISLOCATIONS. 469 

its connection with the tibia and fibuhi being undisturbed. 
Tlie direction of the displacement may be the same as that 
taken by tlie astragakis when dislocated independently, as 
forward, backward, outward, and inward. 

The symptoms are very prominent, chief among them 
being deformity which is marked and characteristic. The 
dislocation is to be distinguished from that of the astragalus, 
which may be done by noting that the relations between 
the tibia and fibula remain undisturbed. 

The prognosis is doubtful owing to the injury necessarily 
inflicted upon the soft parts at the time of the displacement, 
and the great difficulty in eifecting reduction. 

The treatment consists in efforts to replace the displaced 
bone by extension and counter-extension, with manipulation 
and pressure as in dislocation of the astragalus. Subcutane- 
ous section of the tendo Achillis and tendons of the tibialis 
anticus and posticus, or other muscles, should be performed 
if the ordinary methods of reduction fail. If all means fail 
in accomplishing replacement the displaced bone may be al- 
lowed to remain in its abnormal position with the expecta- 
tion that the recovery may ensue with disability, but with a 
limb not entirely devoid of service. If unfavorable symp- 
toms should arise, excision of tlie bone, or amputation by 
Pirogoffor Syme's method should be performed. 

Compound dislocations of the astragalus demand immedi- 
ate excision of the bone or amputation of the foot, as may 
be deemed best. 

In simple dislocations of the astragalus the leg should be 
placed in a fracture box after reduction or after unsuccessful 
efforts at reduction have been made, and applications of 
laudanum and lead- water should be applied. If the inflam- 
mation is severe, local depletion by leeches may be resorted 
40 



470 DISLOCATIONS. 

to and mercurial purgatives administered. Passive motion 
should be employed at an early period to prevent anchy- 
losis. 

Anomalous dislocations of the astragalus have from time 
to time, been reported. The cases reported include displace- 
ment in all directions ; the most remarkable amonoj them beinoj 
the complete reversal of the position of the bone, the head 
looking toward the tendo Achillis and the posterior surface 
in contact with the scaphoid bone. 

Os Calcis. — Dislocation outward of the os calcis, involv- 
ing a separation, partial or complete, from its articulation 
with the cuboid may occur. 

The condition may be recognized by the prominence af- 
forded by the displaced anterior surface of the bone on tlie 
outside of the foot, and the inability of the patient to rotate 
the foot inward or outward owing to the interference with 
the medio-tarsal articulation. 

Reduction may be obtained by extension, the surgeon 
grasping the instep and heel while an assistant makes coun- 
ter-extension from the leg, which is in the flexed position, 
and the bone is pressed into its place. Extension of the 
foot, while abduction and adduction with pressure are made, 
may also effect reduction. 

Scaphoid — A few cases of luxation of this bone have 
been recorded. It may be displaced inward or upward, the 
former direction being the most common. The position of 
the displaced bone will determine the nature of the accident 
as well as the bone involved. Reduction may be effected 
by making extension from the foot, and pressure upon the 
bone. 

Cuboid. — Dislocation of the cuboid alone is a very rare 
accident, and its occurrence is doubted. Instances of the 



DISLOCATIONS. 471 

separation of both scaphoid and cuboid from tlie astragalus 
and OS calcis are recorded. In tlie event of an independent 
luxation of the cuboid, the nature of the displacement could 
be readily determined by careful examination. Reduction 
may be accomplished by extension, with abduction and ad- 
duction and pressure upon the displaced bone. 

Cuneiform Bones Dislocation of the cuneiform bones 

is rare. The internal is most frequently dislocated ; some- 
times all are partially displaced. In luxation of the internal 
cuneiform, the displacement is inward and a marked promi- 
nence exists upon the inner and upper aspect of the foot. 
When two or all are dislocated the displacement is chiefly 
upward. Reduction is effected by extension and counter- 
extension with abduction, so as to separate the metatarsal 
bone of the great toe and the scaphoid, and give space for 
replacement of the bone by pressure. 

After reduction in dislocations of tlie os calcis, scaphoid, 
cuboid, and cuneiform bones, compresses should be placed 
over the replaced bone and held in position by a roller. 
The leg should be supported in a fracture box or between 
bags of sand for two or more weeks. At first the patient 
should walk with the aid of crutches in order to relieve the 
weight upon the foot. 

Metatarsus — Tarso-metatarsal Joints — Ar- 
THRODiAL Articulations — The tarso-metatarsal articu- 
lations are formed by the anterior surfaces of the three 
cuneiform bones and the cuboid, and the bases of the five 
metatarsal bones. The articular surfaces of the different 
tarsal and metatarsal bones differ in shape, that of the 
internal cuneiform and first metatarsal being reniform or 
^•«Wwe^-shaped, while those of the remaining cuneiform, the 
cuboid and metatarsal bones, are triangular, the inner facets 



472 DISLOCATIONS. 

in the cuboid being quadrilateral. A marked peculiarity 
exists in this articulation with regard to the manner in which 
the base of the second metatarsal bone, articulating with the 
middle cuneiform, is deeply wedged in between the external 
and internal cuneiform bones. (Fig. 224.) This arrangement 
provides a very strong articulation and makes this the strong- 
est of all of the tarso-metatarsal joints. The articular sur- 
faces are lined by synovial membranes, three in number, 
and connected together by dorsal, plantar, and three inter- 
osseous ligaments. Two of the interosseous ligaments, the 
internal and middle, attach the base of the second meta- 
tarsal bone to the internal and external cuneiform bones, 
while the third is placed between the external cuneiform 
and third metatarsal bone. 

Metatarsal Joints The bases of the metatarsal 

bones are united by dorsal, plantar, and interosseous liga- 
ments, and the heads or digital extremities by the transverse 
metatarsal ligament. 

Dislocation of individual metatarsal bones or of the entire 
number may occur. The displacement may take place in the 
upward, doivnward, outward, and inward direction. The 
former occurs most frequently. It frequently happens that 
the internal cuneiform is displaced with the first metatarsal 
bone, the former resting upon the scaphoid. 

The cause of dislocation of the metatarsal bones is vio- 
lence applied directly or indirectly, as by blows directly over 
the articulation or by pressure upon the heel, as when the 
foot is caught between the floor and a moving body, the 
toes being in contact with tlie floor and the heel raised. A 
patient came recently under my observation in the surgical 
ward of St. Mary's Hospital, in whom luxation of the first 
metatarsal bone had been produced by the pressure exerted 



DISLOCATIONS. 473 

upon the heel, which was raised (Vom the Hooi* and turned 
out, by a rolling hogshead of tobacco. In this case there was 
marked shortening of the inner surface of the foot, and the 
great toe was inverted. The displacement was upward and 
somewhat outward. 

The symptoms of dislocation of the metatarsal are usually- 
prominent. The displaced bone may be felt in its abnormal 
situation. Shortening of tiie toe is marked. When all of 
the bones are dislocated the foot is much shortened. 

The diagnosis is not difficult, the deformity indicating 
usually the nature of the displacement. 

The treatment consists in effecting reduction by extension, 
with pressure upon the displaced bone. Abduction and adduc- 
tion of the foot should be employed at the same time. If suf- 
ficient force cannot be exerted by grasping the foot with the 
hand it may be necessary to apply the clove hitch. In some 
cases reduction has not been accomplished, the patients 
recovering, however, with good use of the toot. When 
inflammation follows upon the accident, measures should be 
taken to control it. 

In compound dislocation of the metatarsal bones with 
fracture and laceration of the tissues, excision or amputation 
should be performed. 

Phalanges — Metatarso-phalangeal Articulation 
— Partial Exartiirodial Articulation. — These joints 
are formed by the rounded articular surfaces of the heads 
of the metatarsal bones and the concave surfaces of the first 
row of phalanges. The ligaments are the anterior or plan- 
tar and two lateral. The movements of the articulations 
are flexion, extension, abduction, and adduction. 

Phalanges — Phalangeal Articulations — Gingly- 
MOiD Articulations. — Tiiese articulations are formed 

40* 



474 DISLOCATIONS. 

between tlie first and second row and second and third row 
of the phahmges of the toes. The ligaments of the joints 
are the same as those of fingers, anterior and two lateral 
The movements of the joints are limited to flexion and ex- 
tension. Dislocations of the phalanges of the foot are more 
infrequent tlian those of the liand. They may occur at the 
metatarso-plialangealorin the phalangeal articulations ; they 
are most frequent between the first row and the metatarsal 
bones. Displacemeiit of the great toe takes place more 
frequently than that of any of the others. Separation of 
all of the toes at the metatarso-phalangeal articulation lias 
occurred in one reported case. 

The cause of luxation at either the junction with the 
metatarsal bones or between the phalanges, is violence ap- 
plied in falls, twists, or blows. They occur sometimes as 
the result of the toe coming in contact with a fixed object, 
as a displaced brick or flagging in the pavement, the toe 
being stumped against the object. 

The q\\\q^ symptom is deformity, exhibited in the shorten- 
ing and flexion, or extension, witli abduction or adduction 
of the toe. Pain is sometimes marked, the prominence 
formed by the displaced bone is usually easily recognized. 

The diagnosis is generally made without diflficulty. In 
dislocations of the great toe at the metatarso-phalangeal 
junction, dilficulty may be experienced in efiecting reduction, 
rendering the prognosis doubtful in these cases. In unre- 
laxed luxations the impairment of function is usually not 
great. 

The treatment consists in replacing the bone by extension 
combined with pressure. Flexion and extension of the toe 
may facilitate reduction. In cases which resist reduction 
by the usual methods of traction, full extension of the toe 



DISLOCATIONS. 475 

maybe made upon the metatarsal bone and pressure exerted 
against its base, as practised in dislocations of the thumb. 
After reduction, in dislocation of the bones of the metatarsus 
or phalanges, the foot should be surrounded with a suitable 
bandage and placed at rest in a fracture box or between bags 
of sand. It may be necessary, in some instances, where 
there is a tendency to recurience of the displacement to 
apply a splint to the plantar surface and hold it in position 
with a bandage. 

In compound dislocation of the toes excision or ampu- 
tation should be performed. In cases also in which the 
displaced bone cannot be reduced, and it gives rise to great 
deformity with pain in walking, excision or amputation is 
demanded. 



PART V. 
LIGATURE OF ARTERIES. 



1 



The application of ligatures to arteries requires the em- 
ployment of cutting instruments. In performing the opera- 
tions, the methods of holding the knife, of making the inci- 
sions, and of closing the wound, vary. 

Positions of the Knife. There are three principal 
positions in which the knife maybe held. In the Jirst post- 

Fiff. 225. 




tion (Fig. 225), it is held as the pen in writing, the cutting 
edge being turned downward or upward. 



LIGATURE OF ARTEKIES. 



477 




Fi^. 227. 



In the second Fig- 226. 

position (I'Jg' 
226), the handle 
of the instru- 
ment is grasped 
firmly in the 
hand as a table- 
knife is held. 
The handle lies 
in the palm, sup- 
ported strongly 
between the 

thumb, middle, 
ring, and little 
fingers, whilst 
the index finger 
is slightly ex- 
tended along 
the back of the 
blade. In using 
the knife in this 
position, the 
cutting edge may 
be turned up- 
ward or down- 
ward. 

In the third 
position (Fig. 
227), the knife is 
held as the bow 
of the violin — 
lightly balanced between the thumb and fingers. In this 




■*^<s>^ 



Fi-. 228. 




478 LIGATURE OF ARTERIES. 

position, also, the edge may be turned upward or downward 
(Fig. 228). 

Incisions The incisions which are employed may be 

STRAIGHT, CURVILINEAR, OR ANGULAR, and may be made 
from without inward or from within outward. 

The straight incision (Fig. 229) is that most commonly 
used, and may be made in a vertical, oblique, or transverse 
direction. 

The curvilinear incision (Fig. 230) is used where it is 

Fiff. 229. Fi^. 230. Fi^. 231. 



— I \ ^ L V H 



desirable to conform to the shape of the part involved, or 
where large space is required for the purposes of the ope- 
ration. Two curvilinear incisions meeting at tlieir extremi- 
ties form the elliptical (Fig. 230). 

The angular incision (Fig. 231) is composed of two or 
more straight incisions placed at different angles — as the 
rijjht anojle forminji; the letter L, or the acute ano-le forming; 
the letter V, etc. 

In making incisions from without inward, the integument 
should be put upon the stretch ; by this plan the incision is 
made with precision, and the integument is preserved. In 
order to make the incision from within outward, a fold of 
the integument should be held up and its base transfixed by 
the knife, which should cut its way out. This method is 
employed where great caution is required in dividing tne 
superficial tissues. The knife should be held lightly yet 
firmly, and the movements necessary to carry it through 
the tissues should, as a rule, be made w^th the fingers, and 



LIGATURE OF ARTERIES. 479 

not at the wrist or elbow-joint. Very long incisions may 
require a sweeping movement made with the entire arm. 
In cutting from without inward, tlie edge of the knife should 
be held lightly in contact with the surface, not pressed into 
the tissues. " Dexterity, grace, and elegance," in using 
the knife, can be acquired only by practice and careful study. 

Closure of Wounds. — In order to retain the edges of 
wounds in close apposition, so that union may take place, 
the introduction of sutures is necessary. 

The Sutures. — The material used may be silk or linen, 
animal tissue or metal. The metallic suture may be made 
of silver, iron, or lead-wire. The suture may be fastened 
by a square knot, or, as in the metallic suture, by twisting 
the ends or clamping shot upon them. AYhen the metallic 
suture is used in a cavity, as the mouth or vagina, the cut 
ends can be covered by clamping a shot on them, so as to 
prevent them from penetrating the tissues, and thus causing 
pain. The knots or twisted ends should always be placed 
on the side of the incision, and not over it. 

The principal forms of sutures employed are the inter- 
rupted, the CONTINUED, the TWISTED, and the quilled. 

The interrupted, continued^ and quilled sutures are made 
by the insertion of a needle armed with a thread made of 
silk, linen, or wire. 

In the interrupted suture (Figs. 232, 23.3) the needle is 
carried through the edge of the wound from without inward, 
at a proper distance from the border, across the wound, and 
pushed from within outward at exactly the same point on the 
opposite side. The thread is then cut, and another suture 
introduced either above or below. They may be superficial 
or deep (Fig. 234). 



480 



LIGATURE OF ARTERIES. 



The continued suture (Fig. 235) is made by passing the 
needle diagonally from one side of the wound to the other. 
In this suture, the thread is not cut until a sufficient num- 



Fig. 232. 



Fig. 233. 




2g 



'I; 



Fi<-. 234. 



Fig. 235. 



Fig. 236. 




mm ^^\ 





LIGATURE OF ARTERIKS. 



481 



ber of sutures have been introduced to hold the edges in 
apposition. 

The qtiiUed suture (Fig. 236) is formed by passing 
through the lips of the wound a needle armed vvitli a 



Fig. 237. 



Ficr. 238. 





double thread. The ends 
of the thread are tied over 
pieces of quill, bougie, or 
light wood, placed parallel 
to the edge of the incision. 
This suture, as well as the 
beaded suture (Fig. 237), is 
employed in approximating 
the edges of deep wounds. 
The hoisted suture (Fig. 
238) is made by introduc- 
ing a pin made of steel, 
commonly called the hare- 
lip pin, through the edges of the wound, and carrying a 
thread round it in an elliptical manner, so as to hold it in 
place. The pin is passed through the deeper parts of the 
wound, approximating tliem, while the thread brings the 
superficial portions in contact. 

Needles. — The needles employed to pass the threads in 
forming sutures may be either straight or curved, round, 
41 



482 



LIGATURE OF ARTERIES. 



Fig. 239. 



the 
tiss 



triangular,ordou. 
ble-edged (Fig. 
239). They may 
be mounted on 
handles (Fig. 
240), and maybe 
cannulated (Fig. 
241), and pro- 
vided with spe- 
cial appliances for 
facilitating the 
passage of thread 
or wire. In using 

needles with handles they should be passed through the 

Lies, then threaded and withdrawn. 

Fig. 240. 




J.H.GEMRIB. 




OPERATIONS UPON THE LIVING AND DEAD SUBJECTS. 

As the knowledge of the surgeon is to be acquired in 
operations performed upon the dead subject, it is important 



LIGATURE OF ARTERIES. 483 

for liim to understand tliat a marked difference exists with 
regard to the character of the tissues and the manner in 
which they separate under the edge of the knife in the 
living and the dead subjects. This difference should be 
carefully noted, so tliat wlien he undertakes operations upon 
the living subject he may avoid errors. 

In the living subject tlie soft tissues possess a great 
amount of elasticity and power of contractility. The former 
property resides to a marked degree in the common integu- 
ment, and thus adapts it in an admirable manner to the 
purposes of a common covering of the body. In the muscu- 
lar structures tl)e power of contractility is very great, 
varying, of course, in proportion to the size and amount of 
tissue involved. 

In the dead subject these conditions are entirely absent ; 
it is true that in the recently dead subject a small amount 
may exist, but it may, however, be regarded as practically 
wanting. In the subject which has been injected with such 
an agent as chloride of zinc, and kept for a period of time 
in a solution of salt, elasticity and contractility of the tis- 
sues ai-e not only absent, but there exists, in fact, as a result 
of this method of preservation, an induration which is 
altogether unnatural, and which impairs to a great degree 
the value of the subject for anatomical or surgical purposes. 
Tlie color and api)earance of the tissues as well as the tex- 
ture are altered, so that these cannot be taken as guides in 
recognizing different structures. In the living subject a 
very slight exertion will carry a sharp knife easily and 
smoothly through the tissues — almost, it may be said, to 
glide through without any effort on the part of the operator. 
In the dead subject, on the contrary, an effort is required 
to pass the knife through the structures, and in a subject 



484 



LIGATURE OF ARTERIES. 



prepared as above described, some force is necessary to 
divide them. The resistance offered by the tissues of the 
dead subject is well shown in the effort to introduce the 
catheter in the cadaver. Sometimes it is impossible to 
accomplish it, and even when done it has required so much 
force as to inflict injury upon the parts. The information 
derived from the operation is therefore of little practical 
value, since in the living subject the instrument is simply 
guided through the canal, passing almost by its own weight. 
The surgeon will find, therefore, in passing from operations 
upon the dead to those upon the living subject, that unless 
he exercises great caution he will overestimate the resistance 
of the tissues and fail to make his incisions as contemplated. 



INSTRUMENTS USED IN THE LIGATURE OF ARTERIES. 

Fig. 242. Instruments. — The instruments required 

to perform operations for the application of 
ligatures to arteries, are : — 

1. A hnife Thar known as the scalpel, an 

instrument having a sharp point and a broad 
body or belly (Fig. 242). 

2. A pair of dissecting forceps (Fig. 243) 
to seize and hold the tissues, as may be neces- 
sary, in their division. The forceps should 
be held between the thumb and index and 
middle fingers. 

3. A grooved director A blunt-pointed 

director, from four and a half to five inches 
in length, with a groove upon its upper sur- 
face (Fig. 244). It is used to introduce 
beneath lavers of tissue before dividing them, 



LIGATLRE OF AKTERIES. 



485 



an<l also to separate the delicate fascia enveloping ves- 
sels. 

4. A ligature needle. — A curved, blunt-pointed needle 
having an eye near its point, and mounted in a handle so as 
to enable it to be conveniently carried round the artery 
(Fig. 245). 



Fig. 243. Fig. 244. 

n 



Fig. 245. 



Fi-. 246. 




5. Ligatures — Threads made of various materials : silk. 
flax, animal tissue, or metal. They should be cut from four- 
teen to eighteen inches in length. 

6. Retractors — Instruments formed from metal, curved at 

41* 



48G LIGATURE OF AETERIES. 

one extremity, and of sufficient length and breadth to hold 
conveniently the edges of the wound apart (Fig. 246). 

7. Sci'sso}'S — The ordinary straight surgical scissors. 

8. Suture needles. 

9. Sutures. 

In performing the operation upon the living subject, 
there would be needed, in addition, adhesive plaster, cut 
into strips, to support the edges of the wound, a compress 
to cover the surface of the wound, and a roller to confine 
the dressings and afford gentle support to tlie parts. 

OPERATIONS FOR THE LIGATURE 
OF ARTERIES. 

General Considerations. — In order to perform the 
operation for the ligature of arteries properly, it is essential 
that the surgeon should have a thorough knowledge of the 
anatomical relations of the structures concerned in the 
operation. He should be able, as it were, to see through 
the parts — to have a mental picture of the structures, layer 
after layer, from the surface to the position occupied by the 
vessel. He should have such familiarity with the appear- 
ance of the various tissues as will enable him to distinguish 
them promptly — their color and the arrangement of their 
fibres. He should know so well the course of the vessel 
that he can make the incision directly over and parallel to 
it, and not across it. He should not commence the incision 
by hunting for the artery, but should proceed intelligently, 
seeking as he advances for well-known and well-established 
guides or landmarks, structures of importance and having 
important relations to the vessel he seeks. 

The student, in operating upon the cadaver, is especially 



LIGATURE OF AKTERIES. 487 

cautioned against want of care and undue haste ; it is too 
frequently observed that many are satisfied with simply 
finding the vessel, without possessing any definite knowl- 
edge with regard to its position and relations. As a result 
of such imperfect methods it not infrequently happens that 
the ligature is found to surround a vein, nerve, tendon, or 
even a portion of muscular tissue or fascia, instead of the 
artery. 

Every operation performed for the ligature of an artery 
can be divided into three well-defined stages. The first 
stage embraces that part of the operation which relates to 
reaching or exposing the artery or its sheath ; the second 
includes the isolation or separation of the artery from the 
surrounding or accompanying structures; in the third, the 
operation is completed by the application of the ligature and 
the closure of the wound. It is in the first stage of the 
operation that the anatomical knowledge of the operator is 
especially to be brought into play. He should carefully 
inspect the limb or part so as to fix the important external 
landmarks or surface markings ; he should also feel it, so as 
to determine the nature of the structures causing projections 
upon the surfaces. He should fix accurately the points 
between which the vessel passes, and define its course ; he 
should recall its general relations in its entire extent, and 
its particular relations at the point of ligation. He should 
note carefully the character of the structures having particu- 
lar relations, whether bloodvessels or nerves, and therefore 
to be approached with great caution, or muscles or tendons 
which serve as rallying points or guides. After the incision 
of the skin and superficial fascia has been made, these 
guides should be sought for in order until the vessel is 
reached. 



488 LIGATURE OF ARTEKIES. 

When the artery has a sheath, inclosing with it a vein or 
a vein and a nerve, its isolation should be effected with 
great care, so as to avoid inflicting injury upon the accom- 
panying structures. 

As the coats of the artery receive their vascular supply 
from the nutrient vessels which ramify in the loose areolar 
tissue connecting the artery with the sheath, it is important 
that this should be destroyed to as slight an extent as pos- 
sible. As a rule, the separation should not be more than 
one-half of an inch. This rule should be observed in sepa- 
rating the artery from surrounding structures, under all 
circumstances, as suppuration is more liable to occur when 
the tissues are much disturbed and broken up. 

In passing the ligature round the artery, the point of the 
instrument should be carried always from the vein so that 
the point cannot penetrate it ; if a vein is not present, then 
the ligature should be passed from the nerve. If the vessel 
is accompanied by vena3 comites, these should be gently 
separated before passing the ligature. Before tying the 
ligature, careful examination should be made to see that the 
nerve is not included. 

In making the incisions to expose the artery, the skin 
over the part to be divided should be held firmly between 
the thumb and index finger of the left iiand, while the knife, 
held in the position of the pen in writing, should be intro- 
duced in a vertical direction, the point penetrating the skin, 
and, to a slight extent, the superficial fascia ; then, de- 
pressing the handle of the knife, it is drawn downward or 
upward as the case maybe, dividing the tissues to the proper 
extent, and withdrawn in the vertical direction, the move- 
ments necessary to accomplish this being made by the 
fingers and not at the wrist-joint. This first incision should 



LIGATURE OF AUTEKIES. 



489 



be free and cleanly cut. The fascia is now seized by the 
dissecting forceps at the lower angle of tlie incision, elevated, 
and a small incision is made with the scalpel (Fig. 247). 
Through tliis opening the point of the grooved director is 
introduced, and gently pushed to the upper angle of the 



Fiff. 247. 



Fig. 248. 




incision. The knife is now carried along the groove (Fig. 
228), dividing the fascia and liberating the director. Before 
incising the fascia raised upon the director, it should be 
examined carefully in order to detect any vessels or nerves 
which it may contain. If these are of sufficient importance 
they can be held aside, while the fascia is divided, or, if 
necessary, the vessels may be tied with double ligatures and 
then divided between the ligatures. Each layer of tissue is to 



490 



LIGATURE OF ARTERIES. 



be divided in this manner until the vsheath of the artery is 
reached. This is opened by seizing it with the forceps and 
making a slight nick, of sufficient size, to admit the point of 
the ligature needle. Tiirough this opening the point of the 
grooved director is inserted, and the artery is gently and cau- 
tiously separated from the sheath and the accompanyingstruct- 
ures. The ligature needle, having been armed, is now intro- 
duced through the opening, the point kept in close contact 
with the artery and carried around it in a direction from the 
vein or nerve, and brought out on the opposite side. One 
thread of the ligature is now seized with the forceps, and 
held firmly while the needle is witlidrawn. 

The artery thus surrounded should be raised gently from 
its bed, and examined to see that no other structure is in- 
cluded in the ligature. This being determined the ligature 
is tied, as shown in Fig. 248, with a square or reef knot 
(Fig. 249), or surgeon's knot (Fig. 250), care being taken to 



Fis. 249. 



250. 





C^S^ 



avoid making the " granny" knot, which is liable to slip 
(Fig. 251) ; one end is cut ott' close to the knot, and the 
remaining one is allowed to pass directly out of the wound. 
The wound is now closed by two or more sutures, the 



LIGATURE OF ARTERIES. 



491 



Fig. 251. 




knots being placed on one side of the incision and not over 
it, adliesive strips and compress are applied, and the parts 
gentl}' supported by a few turns 
of the roller. 

Some of the more important 
points relating to the different 
steps of the operation may be 
embraced in a few general rules, 
which will assist the surgeon in 
fixing them upon his mind. 

I. Make the incision directly 
over and parallel to the course of 
the artery, not across it. Unless 
the incision is made very wide 
of the course of the vessel, this plan will give ample room. 
The tissues can be separated by the retractors, so as to in- 
crease the space, when required. If the oblique incision is 
made, and is carried into the deeper part of the wound, the 
muscular structures would be divided across their fibres, 
which is objectionable, and not parallel with them. 

II. Dissect directly down to the artery. Avoid lateral 
dissections and disturbance of the surrounding structures. 

III. Separate the artery from its sheath to the slightest 
extent possible. 

IV. Do not use the point of the knife in the wound after 
the sheath of the vessel has been reached and opened. 
Use the handle of the knife and the grooved director to 
separate tissues. 

V. Always pass the ligature from the vein, if present. 

VI. Make the incision as small as possible, but always 
large enough to give ample working space and light. The 
external incision should be made to the extent required by 



492 LIGATURE OF ARTERIES. 

the first stroke of the knife, so as to avoid subsequent 
incisions to enlarge it. These, when made, usually result 
in the production of irregular, jagged edges. A superficial 
artery requires a short incision, one lying deeper a longer 
incision. 

VII. In closing the wound, the needle should be inserted 
at such distance and depth from the edge as to resist ten- 
sion — as a rule, not less than half a line, nor more than a 
quarter of an inch. Two-thirds of the thickness of the edge 
should be supported by the suture. 

In describing the application of ligatures to the various ar- 
teries, a plan has been adopted which, it is thought, will assist 
the surgeon materially, not only in performing the operations, 
but in studying them. An effort has been made to present 
the subject in a systematic manner, so that when the opera- 
tion is undertaken he will find information which will enable 
him to proceed intelligently through each step, and, when 
finished, study it as a complete operation. 

In each description the following order has been ob- 
served : — 

I. The course of the vessel is stated, the direction 
which it takes in passing between certain points — fixed or 
imaginary. 

II. External guides or surface markings are given. 
These may exist as bony projections or borders of muscles 
which appear prominently upon the surface ; they are im- 
portant in fixing the relations of the vessel to the external 
surface. 

III. The general anatomical relations which the vessel 
has are given in detail, and also the particular relations at 
the point of application of the ligature. These acquaint the 



THE INNOMINATE ARTERY. 



493 



s*irgeoii with the entire surroundings of the vessel, inform- 
ing liim of their nature. 

IV. Internal guides, landmarks, or rallying points, which 
are to be sought for as the operation progresses, are noted 
in each case. 

V. Certain structures, as veins and nerves, have rela- 
tions to each important artery, and are to be carefully 
avoided. These are stated in the order of their importance, 
and in certain operations special attention is directed to 
their presence. 

YI. Some of the larger arteries are embraced in a common 
sheath with the vein, and sometimes a nerve. When this 
arrangement exists it is stated. 

LIGATURE OF SPECIAL ARTERIES. 

The Innominate Artery — Surgical Anatomy — 
Before attempting to ligate this vessel the surgeon should 
endeavor to obtain a clear idea of the relations it has to the 



1,1. luternal jugular veins. 

2. 2. Subclavian veins. 

3. Right innominate vein. 

4. Left innominate vein. 

5. Inferior thyroid vein. 

6. External jugular vein. 

7. Arch of the aorta. 
S. Innominate artery. 

9, 9. Conimou carotid arteries. 
10, 10. Suhelavian arteries. 




Innominate Artery. 



very important structures which surround it. It is the 
largest branch given off from the arch of the aorta, and is 
from an inch and a half to two inches in length (Fig. 252). 
42 



494: LIGATURE OF ARTERIES. 

Its point of origin, from the transverse portion of tlie aorta, 
is about one inch below the margin of the sternum, and on 
a line with the second costo-sternal articulation. It is in 
intimate relation with the two large venous trunks — the 
right and left innominate veins — the right inferior thyroid 
vein crossing its front in an oblique direction. On the right 
side it has in close proximity the right pneuraogastric nerve 
and the pleura; it rests upon the trachea, and to the left has 
in relation the left carotid artery. It will be observed, 
therefore, that on all sides are placed the most important 
structures, which require the utmost care to avoid. Not 
only should these structures be carefully guarded against 
injury, but in any operation which is performed they should 
be disturbed to the sliglitest extent possible. The causes of 
failure in efforts which have been made to surround this 
vessel with a ligature in the living subject are stated to have 
been repeated secondary hemorrhages and inflammation of 
the pleura and lung. 

Course. — Obliquely upward from point of origin from the 
commencement of the transverse portion of the arch of 
the aorta to the sterno-clavicular articulation of the right 
side. 

Surface markings Sterno-clavicular articulation. Fossa 

above the clavicle, indicating the interval between the two 
heads of the sterno-cleido-mastoid muscle. 

General relations. — Jn front Sternum, sterno-hyoid, 

and sterno-thyroid muscles ; remains of thymus gland ; left 
innominate and right inferior thyroid veins, and cardiac 
branches of the right pneumogastric nerve. 

Behind. — The trachea. 

Right side Right innominate vein, pneumogastric nerve, 

and the right pleura. 



THE INNOMINATE ARTERY. 495 

Left side — Remains of the thymus gland and the left car- 
otid artery. 

Guide The sterno-cleido-mastoid muscle. 

Structures to he avoided The middle and right inferior 

thyroid, the anterior and internal jugular, and the right in- 
nominate veins ; the pneumogastric nerve. 

Operation Raising the shoulders, inclining the head 

slightly backward and to the left side, so as to render tense 
the right sterno-mastoid muscle, and project the innominate 
artery into the neck, an incision, three inches in length, di- 
viding the skin, should be made from below the clavicle up- 
ward over the fossa, indicating the interval between the two 
heads of the sterno-mastoid muscle. The superficial fascia, 
platysma myoides, and anterior layer of the deep fascia, are 
now carefully divided on the grooved director. Flex the 
head slightly, and separate with the fingers the heads of the 
sterno-mastoid muscle, the connecting areolar tissue having 
been divided. Divide carefully on the director the deep 
layers of the cervical fascia, and, if necessary, the sterno- 
iiyoid and sterno-thyroid muscles transversely. These in- 
cisions will expose the point of bifurcation of the artery into 
the carotid and subclavian arteries. Passing downward from 
this point the artery can be reached, and the ligature applied 
from right to left, so as to avoid the right innominate vein 
(Fig. 253). 

The innominate artery can also be reached by an inci- 
sion, two inches in length, made along the anterior border 
of the sterno-mastoid muscle, terminating at the clavicle. 
From this point a second incision, to the same extent, 
is carried along the upper border of the clavicle. The 
points of attachment of the platysma, the sterno-mastoid, 
sterno-thyroid, and sterno-hyoid muscles are to be divided 



496 



LIGATURE OF ARTERIES. 



as they are exposed. Dividing carefully the fascia, and 
separating other structures, the right carotid artery is brought 
into view ; tracing this downward, the innominate artery 
can be reached and ligatured. 

The advantages claimed for the method first described 
are, in avoiding the section of the muscles, and the greater 



Fig. 253. 




1. Internal head of sterno-mastoid muscle. 

2. External bead of sterno-mastoid muscle. 

3. Vertebral artery. 

4. Pneumogastric nerve. 

5. Recurrent laryngeal nerve. 

6. Internal jugular vein pulled aside. 

7. First part of subclavian artery and its branches. 

8. Innominate artery. 

ease with which the artery is approached. While, in all 
cases, it is desirable to divide the tissues to as slight an ex- 



THE TRIANGLES OF THE NECK. 



497 



tent as possible, it is, nevertheless, of great importance that 
the operator should not be embarrassed by want of ample 
working space. Great injuries may be inflicted upon struc- 
tures in the eftbrt to save those of less importance. In this 
operation it is sometimes impossible to avoid wounding some 
of the larger venous branches in relation with the artery ; 
when this occurs they should be ligated, or, when it is nec- 
essary to divide them, two ligatures should be applied, and 
the vein cut between. 

The Triangles of the Neck. — Before passing to the 
operations upon the arteries which occupy the region of the 

Fiff. 254. 



1. Posterior belly of the di- 

gastric muscle. 

2. Anterior belly of the digas- 

tric. 

3. Anterior belly of the omo- 

hyoid muscle. 

4. Posterior belly of the omo- 

hyoid. 

5. Sterno-cleido-mastoid maa- 

cle. 

6. Trapezius muscle. 

a. Digastric, or submaxillary 

triangle. 

b. Superior carotid triangle, or 

triangle of election. 

c. Inferior carotid triangle, or 

triangle of necessity. 

d. Occipital triangle. 
€. Subclavian triangle. 




Triangles of the ^Teck. 



neck, the surgeon should, in connection with the study of 
their relative anatomy, also carefully examine these struc- 
tures collectively. On examination it will be found that 

42* 



498 LIGA.TUUE OF ARTERIES. 

these vessels, with other important structures, occupy certain 
well-defined spaces, which can be readily outlined, and 
which are formed by prominent muscular and bony structures 
(Fig. 254). The side of the neck is somewhat quadrilateral 
in shape ; bounded above by the lower border of the body 
of the jaw and an imaginary line extending from the angle 
of the jaw to the mastoid process of the temporal bone ; 
below, by the upper border of the clavicle ; in front, by the 
median line of the neck ; and behind, by the border of the 
trapezius muscle. The sterno-mastoid muscle, crossing this 
space obliquely, divides it into two large triangles, the ante- 
rior and posterior. The former is bounded by the median 
line of the neck in front, the anterior border of the sterno- 
mastoid behind, and the border of the jaw and the imaginary 
line from the angle to the mastoid process above. This tri- 
angle is subdivided by the digastric and anterior belly of the 
omo-hyoid muscle into three smaller triangular spaces, named, 
from below upward, the inferior carotid, the superior carotid, 
and the digastric. 

The inferior carotid triangle, or the " triangle of neces- 
sity,'" as it is sometimes designated, is formed by the 
median line of the neck in front, by the anterior border of 
the sterno-mastoid behind, and by the anterior belly of 
the omo-hyoid above. The common carotid artery passes 
through this space obliquely upward and backward, follow- 
ing the direction of the sterno-mastoid muscle, covered in 
part by the muscles which take origin from the sternum and 
clavicle. 

The superior carotid triangle, or the " triangle of elec- 
tion,''^ is bounded by the posterior belly of the digastric 
above, the anterior belly of the omo-hyoid below, and the 
anterior margin of the sterno-mastoid behind. In this space 



THE COMMON CAROTID ARTERY. 499 

the common carotid artery lies superficial, and at the upper 
border of the tliyroid cartilage divides into its terminal 
branches, the external and internal carotids. 

The digastric triangle is limited above by the lower bor- 
der of the jaw, tlie parotid gland, and mastoid process of 
the temporal bone ; behind by the posterior belly of the 
digastric and stylo-hyoid muscles, and in front by the 
anterior belly of the digastric muscle. The external and 
internal carotid arteries, with the internal jugular vein and 
pneumogastric nerve, pass through this space. 

The posterior triangle is subdivided into two smaller tri- 
angles, by the posterior belly of the omo-hyoid muscle, the 
occipital and the subclavian. 

The occipital triangle is bounded, in front, by the poste- 
rior border of the sterno-mastoid ; behind, by the anterior 
border of the trapezius ; and, below, by the posterior belly 
of the omo-hyoid. 

The subclavian, the smaller and more important of the 
posterior subdivisions, is formed by the posterior border of 
the sterno-mastoid in front, the upper border of the clavicle 
below, and the posterior belly of the omo-hyoid above. In 
this space is found the subclavian artery as it arches across 
the root of the neck. 

The Common Carotid Artery. — Surgical Anat- 
omy For the purposes of ligation, the common carotid 

artery may be divided into two parts, that above the ante- 
rior belly of the omo-hyoid muscle extending to the point 
of bifurcation opposite the upper border of the thyroid car- 
tilage, and that below the muscle terminating at the sterno- 
clavicular articulation (Fig. 255). The upper portion lies 
in the superior carotid triangle (Fig. 254, h). Owing to the 



500 



LIGATCRE OF ARTERIES. 



superficial position it occupies in this space, it is easily 
reached, and this is designated as the point of selection. 
At this part it is crossed obliquely from within outward by 
the sterno- mastoid artery, a branch of the superior thyroid 
(the superficial descending branch), and also by the facial, 
lingual, and superior thyroid veins, which terminate in the 



Fiff. 255. 




The Common Carotid Artery. 



1. Sterno-thyroid muscle. 

2. Omo-hyoid muscle. 

3. 3. Extremities of the 
Sterno - cleido - mastoid 
muscle which has been 
divided. 

4. Masseter muscle. 

5. Common carotid artery, 
with filaments of descen- 
dens noni nerve on its 
anterior surface. 

6. Internal jugular vein. 

7. Pneumogastric nerve. 

8. External carotid artery. 

9. Facial artery with vein. 

10. Internal carotid artery. 

11. Hypoglossal nerve 
crossing the external ca- 
rotid artery. 

12. Lingual artery. 



internal jugular. Below the omo-hyoid muscle the vessel 
occupies the inferior carotid triangle (Fig. 254, c). Here 
it is deeply placed, lying beneath the sterno-mastoid, sterno- 
thyroid, and sterno-hyoid muscles which take origin from 
the adjacent parts of the sternum and clavicle. 

In this position, which is designated the triangle of neces- 
sity, its relations are somewhat more complicated than 
above, owing to the proximity of the vessels and other 



THE COMMON CAROTID ARTERY. oOl 

structures which converge to the root of the neck. On the 
right side the internal jugidar vein separates from the 
artery, while on the left it approaches, and usually crosses, 
its lower part, in order to unite with the subclavian vein. 

It is also to be remembered that the carotid arteries 
present, frequently, peculiarities relating to origin, point of 
bifurcation, and branches. In a surgical point of view, the 
most important peculiarity is that which relates to the 
point of division in the neck. In the order of infrequency, 
the points of division are given as the root of the neck, 
opposite the middle of the larynx or lower border of the 
cricoid cartilage, opposite the hyoid bone or beyond this 
point. 

The artery occasionally gives origin to the superior thy- 
roid or a laryngeal branch, tlie inferior thyroid or, very 
rarely, the vertebral artery. 

After ligature of the common carotid artery, the col- 
lateral circulation is freely established both within and 
without the cranium by the branches of both carotid 
arteries and those of the subclavian artery on the side on 
which the ligature has been applied. Outside, the superior 
and inferior thyroid and the profunda cervicis of the 
superior intercostal and arteria princeps cervicis of the 
occipital, form the principal channels of communication, 
while, within the cranium, the vertebral artery takes the 
place of the internal carotid. 

Course — From the sterno-clavicular articulation upward 
and backward to a point midway between the mastoid pro- 
cess of the temporal bone and the angle of the lower jaw. 

Surface marking — The sterno-cleido-mastoid muscle. 

General relations — Above the Omo-hyoid Muscle. — In 
front. — Skin, superficial fascia, platysma and deep fascia, 



502 LIGATURE OF ARTERIES. 

anterior border of sterno-mastoid muscle, facial, lingual, 
and superior thyroid veins, sterno-mastoid artery, descen- 
dens noni nerve. 

Below the Omo-hyoid Muscle In front Skin, super- 
ficial fascia, platysma and deep fascia, sternal head of the 
sterno-mastoid, sterno-hyoid and thyroid muscles, anterior 
jugular and middle thyroid veins. 

Behind. — Longus colli and rectus anticus major muscles, 
sympathetic nerve, inferior thyroid artery, and recurrent 
laryngeal nerve. 

Inside. — Pharynx, larynx, inferior thyroid artery, recur- 
rent laryngeal nerve, thyroid gland, and trachea. 

Outside Internal jugular vein and pneumogastric nerve. 

Guide. — The sterno-cleido-mastoid muscle. 

Structures to he avoided — Internal and anterior jugular 
veins, sterno-mastoid artery, descendens noni, and pneu- 
mogastric nerve. In the lower portion, the inferior 
thyroid artery, recurrent laryngeal, and sympathetic 
nerves. 

Common sheath Including the artery on the inside, 

internal jugular vein on the outside, and the pneumogas- 
tric nerve behind and to the outside. 

Operation Above the omo-hyoid muscle ; in the tri- 
angle of election. 

The head being thrown back and the face turned to the 
opposite side, an incision, from two and a half to three 
inches in length, is made, beginning opposite the greater 
cornu of the hyoid bone and passing downward along the 
anterior border of the sterno-mastoid muscle, dividing the 
skin. The superficial fascia, platysma muscle, and the 
layers of the deep fascia being divided carefully upon the 
director, the inner edge of the sterno-mastoid muscle is ex- 



THE COMMON CAROTID ARTERY. 



503 



posed. Lying beneatli this, separated by a layer of the 
deep fascia, is found the common sheath of the vessels, 
with the descendens noni nerve upon its anterior surface. 
Pushing tliis gently aside, the common sheath is now to 
be opened to a very slight extent, the artery separated 
gently from the vein and nerve, and the ligature passed in 
a direction from the vein, being careful to avoid the nerve 
(Fig. 256). 

Fig. 256. 




1. Anterior belly of the omo-hyoid muscle. 

2. Commou carotid artery, with desceadeas noni nerve on its anterior surface. 

3. Internal jugular vein. 

4. Pneuraogastric nerve. 

5. Sterno-mastoid muscle drawn aside. 



Operation — Below the omo-hyoid muscle in the trian- 
gle of necessity. 

An incision from two and a half to three inches in 
length should be made from opposite the cricoid cartilage 
to a point one-quarter of an inch above the sternum along 



504 LIGATURE OF ARTERIES. 

the inner edge of the sterno-mastoid muscle, dividing the 
skin. The superficial fascia, platysma, and the layers of 
the deep fascia should be carefully divided upon the direc- 
tor, exposing the sterno-mastoid muscle. Turning the head 
towards the side operated on, and slightly flexing it, so as 
to relax the muscles, the sterno-mastoid is drawn to the 
outer side, and the sterno-hyoid and sterno-thyroid muscles 
to the inner side. The sheath of the vessels, lying beneath 
the layers of the deep fascia, which should be divided, is 
opened carefully, and the ligature passed from the vein, care 
being taken to avoid the pneumogastric and the descendens 
noni nerve, w^hich latter here lies somewhat to the inner 
side (Fig. 256). 

In performing the operation above the omo-hyoid muscle, 
the surgeon should bear in mind the direction w^iich the 
anterior belly of this muscle takes in passing to its point of 
insertion on the hyoid bone, and the point at which it crosses 
the artery. From its point of origin on the upper border of 
the scapula, it passes forward across the root of the neck, 
leaving the line of the upper border of the clavicle gradually 
until it reaches the sterno-mastoid muscle, behind which it 
becomes tendinous and changes its direction, ascending 
almost vertically upward to the hyoid bone, forming an 
obtuse angle. This direction takes it across the artery at a 
point slightly below the middle ; as the ligature should be 
applied just above its upper border, the middle point of the 
artery should be ascertained, and the incision made so as to 
expose this part. This point corresponds to the loiver bor- 
der of the larynx, and can, therefore, be easily fixed. The 
upper part of the artery, just below tlie point of bifurcation, 
should not be chosen for the application of tlie ligature, 
owing to the position in front, of the facial, lingual, and 



THE EXTERNAL CAROTID ARTERY. 505 

superior thyroid veins. Attention is also directed to the 
intimate relation which the internal jugular vein has to the 
artery ; the large column of blood it carries brings it promi- 
nently into the wound, and the extreme thinness of its walls 
renders it liable to be easily wounded. 

In the operation below the omo-hyoid muscle, the rela- 
tions of the middle thyroid vein, the inferior thyroid artery, 
and the recurrent laryngeal nerve, with the position of the 
internal jugular vein across the artery at the root of the 
neck on the left side, should be borne in mind. 

The importance of the sterno-mastoid muscle as a guide 
to the carotid artery, should not be forgotten. In its entire 
extent it may be said to be covered and protected by this 
muscle, being placed well under it in the first part of its 
course, and gradually approaching its anterior border as it 
ascends the neck. The muscle is embraced between two 
layers of the deep cervical fascia, which unite at its anterior 
border. When the fibres of the muscle are exposed in the 
operation, it is to be remembered that but one layer of the 
envelope of the muscle has been divided, and that another 
lies beneath, separating the muscle from the sheath of the 
vessels, which must be divided before the sheath is reached. 

The External Carotid Artery -Surgical Anato- 
my. — Owing to the complicated relations of this vessel, and 
the number of branches given off from it, ligation, except in 
cases of wounds, is rarely performed. If necessary, a liga- 
ture may be applied near its origin or above the posterior 
belly of the digastric muscle. In the first part of its course, 
the artery lies in the triangular space formed by the sterno- 
mastoid behind, the anterior belly of the omo-hyoid below, 
and the posterior belly of the digastric above. In this space 
43 



506 LIGATURE OP ARTERIES. 

it is crossed by the facial and lingual veins and by the 
hypoglossal nerve below the tendon of the digastric muscle. 
As it ascends it gets beneath the digastric muscle, and 
passes deeply into the substance of the parotid gland, where 
it is crossed by the facial nerve (Figs. 255, 8). 

Course From the upper border of the thyroid cartilage 

upward, forward, and backward to the space between the 
neck of the condyle of the lower jaw and the external audi- 
tory meatus. 

Surface markings. — Sterno-mastoid muscle and posterior 
border of the ramus of the lower jaw. 

General relations In front. — Skin, superficial fascia, 

platysma muscle, deep fascia, hypoglossal nerve, facial and 
lingual veins, digastric and stylo-hyoid muscles. 

BeJiind Superior laryngeal and glosso-pharyngeal nerves, 

stylo-glossus and stylo-pharyngeus muscles. 

Internally Hyoid bone and pharynx, ramus of the lower 

jaw. 

Guides Below, sterno-mastoid muscle; above, posterior 

belly of the digastric muscle and the parotid gland. 

Structures to he avoided Lingual and facial veins, and 

hypoglossal nerve. 

Operation At the point of origin of this artery the 

ligature may be applied by the same plan of operation as 
that adopted in the ligature of the common carotid artery 
above the omo-hyoid muscle (Fig. 256). The incision is 
made from a point opposite the greater cornu of the hyoid 
bone, downward to the extent of two and one-half to three 
inches, dividing the skin. The superficial fascia, platysma 
muscle, and deep fascia are divided on the director, expos- 
ing the sheath of the vessel, which is opened, and the liga- 
ture is passed from without inward, care being taken to 



THE SUPKRIOR THYROID ARTERY. 507 

avoid the internal carotid artery which lies behind and 
somewhat externah 

Above the posterior belly of the digastric muscle, the 
artery is reached by an incision extending from the lobe of 
the ear to the great cornu of the hyoid bone, dividing the 
skin. The superficial fascia, platysma, and deep fascia 
are divided carefully on the director, exposing the parotid 
gland. The posterior belly of the digastric, with the stylo- 
hyoid muscle, are found below at the bottom of the wound, 
and are to be separated from the parotid gland above, when 
the artery will be exposed before its entrance into the sub- 
stance of the gland. 

In applying a ligature to the artery at this point, the sur- 
geon should recall the position of the numerous venous trunks 
which occupy this region. Some of these are necessarily 
divided, and give rise to considerable hemorrhage, which com- 
plicates the operation. When necessary, these should be tied 
with two ligatures, and then divided. If cut before being 
tied, and the amount of hemorrhage warrants it, a ligature 
should be applied as in the arteries. In this region, also, 
there will be found most important structures, vessels, and 
nerves, which are to be dealt with cautiously. 

The Superior Thyroid Artery Surgical Ana- 
tomy. — This vessel is the first branch of the external caro- 
tid artery, being given off just above the point of bifurcation 
(Fig. 255). It lies superficially in the triangle of election 
at the beginning of its course, and can be reached readily. 

Course — From the point of origin below the greater 
cornu of the hyoid bone upward and inward, then curving 
downward and forward to the upper part of the thyroid 
gland. 



508 



LIGATURE OF ARTERIES. 



Fiff. 257. 



Surface markings Sterno-mastoid muscle and greater 

cornu of the hyoid bone. 

General relations The same in the first part of the 

artery as those of the external carotid. 

Guide Greater cornu of the hy- 
oid bone. 

Structure to he avoided. — The 
superior thyroid vein. 

Operation The incision to be 

made in applying a ligature to this 
vessel is on the same line, but some- 
what internal to that made for expos- 
ing the external carotid. The super- 
ficial structures are to be divided, 
when the vessel will be brought into 
view, as it ascends (Fig. 257). 




The Lingual Artery Surgical Anatomy. — This 

artery is the second branch of the external carotid given off 
from its anterior surface (Fig. 255, 12). 

Course From the external carotid artery just below the 

greater cornu of the hyoid bone obliquely upward and 
inward, horizontally forward parallel to the greater cornu, 
and then vertically upward to the under surface of the 
tongue. 

Surface marking. — Hyoid bone. 

General relations — First portion. — In front Skin, 

superficial fascia, platysma, and deep fascia. 

Behind Middle constrictor muscle. 

Above Hyoid bone. 

Below. — Thyroid cartilage. 



THE FACIAL ARTERY. 509 

Second portion. — In front Superficial structures, with 

the digastric and stylo-hyoid muscles and hypoglossal nerve. 

Behind — Middle constrictor muscle. 

Below. — Greater cornu of the hyoid bone. 

Above Muscles of the tongue. 

Guides Posterior belly of the digastric muscle and the 

hypoglossal nerve. 

Structure to be avoided. — Hypoglossal nerve. 

Operation A transverse incision is made along the 

upper border of tlie hyoid bone from a point in the median 
line of the neck a little below the symphysis of the lower 
jaw to near the border of the sterno-mastoid muscle, dividing 
tiie skin. The superficial fascia, platysma, and deep fascia 
should be divided on the director. Seek for the posterior 
belly of the digastric muscle and liypoglossal nerve. The 
artery will be found along the upper border of the great 
cornu of the hyoid bone just as it passes beneath the 
hypoglossus muscle. If not found at this point, it may be 
necessary to divide the attachment of the hypoglossus muscle 
in order to reach the vessel and apply the ligature. Care 
should be taken to avoid the hypoglossal nerve (Fig. 257). 

The Facial Artery. — Surgical Anatomy This 

is the third branch given off from the anterior surface of the 
external carotid artery, and may be ligatured as it passes over 
the border of the lower jaw, at the anterior inferior angle of 
the masseter muscle (Fig. 255, 9). 

Course — From the point of origin a short distance above 
the cornu of the hyoid bone, obliquely forward and upward 
to the submaxillary gland, passing through a groove on its 
upper surface and upward over the body of the lower jaw at 
the anterior inferior angle of the masseter muscle ; forward 

43* 



510 LIGATURE OF ARTERIES. 

and upward to the angle of the mouth, upward along the 
side of the nose, terminating at the inner canthus of the eye. 

Surface marlcing Masseter muscle. 

Relations at the point of ligature In front Skin and 

superficial fascia. 

Behind Body of the lower jaw. 

Externally The masseter muscle and facial vein. 

Internally — The depressor anguli oris muscle. 

Guide — The anterior inferior angle of the masseter 
muscle. 

Structure to he avoided The facial vein. 

Operation — Fix the position of the anterior inferior 
angle of the masseter muscle, and make an incision, one 
inch in length, in the line of the artery, dividing the skin. 
The superficial fascia and fibres of the platysma muscle 
being divided on the director, the artery will be exposed 
with the vein to the outside. The ligature is to be passed, 
avoiding the vein (Fig. 257). 

The Temporal Artery. — Surgical Anatomy 

This artery is the smaller of the two terminal branches of 
the the external carotid, and takes its origin in the substance 
of the parotid gland at a point midway between the neck of 
the condyle of the lower jaw and the external auditory 
meatus. Two inches above the root of the zygoma, over 
which it passes, it divides into the anterior and posterior 
temporal branches. 

Course From the interspace between the neck of the 

condyle of the lower jaw and the external meatus, directly 
upwards over the root of the zygoma. 

Surface marhing Root of the zygoma. 

General relations In front. — Skin, superficial fascia, 



Tin: OCCIPITAL ARTEUY. 511 

jittrahens aurem muscle, and dense foscia from over the 
parotid gland ; superficial veins and nerves. 

Behind Zygomatic arch. 

Outside External auditory meatus. 

Inside Origin of masseter muscle. 

Guide — Zygomatic arch. 

Structures to be avo/c?ec?.-— Temporal vein and branches 
of auriculo-temporal nerve. 

Operation An incision one inch in length and one- 
third of an inch in front of the tragus should be made in 
the line of the vessel, dividing the skin. The superficial 
fascia, attrahens aurem muscle, and parotid fascia are to be 
divided carefully on the director, and the artery will be 
found lying on the zygoma. The vein which lies to the 
outside should be avoided in passing the ligature (Fig. 257). 

The Occipital Artery Surgical Anatomy. — 

The occipital artery is the first branch of the external 
carotid arising from the posterior part. 

Course — From the point of origin near the lower margin 
of the digastric muscle obliquely upward across the internal 
carotid to a point between the transvere process of the atlas 
and the mastoid process of the temporal bone, then hori- 
zontally backward in a groove on the surface of the bone, 
and vertically upward to the occiput. 

Surface marking Mastoid process of temporal bone. 

Relations at point of ligation In front Skin, aponeu- 
rosis of the sterno-mastoid muscle, splenius, digastric, and 
trachelo-mastoid muscles. 

Behind — Complexus, superior oblique, and rectus posti- 
cus major muscles. 

(tm^c/^,— Mastoid process. 



512 LIGATURE OF ARTERIES. 

Structure to he avoided — Occipital vein. 

Operation. — The artery can be reached by making an 
incision one inch and a half in length over its course from 
the mastoid process of the temporal bone to the external 
occipital protuberance, dividing the skin. The fascia, 
aponeurosis of the sterno-mastoid muscle, and the splenius 
capitis muscle must be divided, when the artery will be 
exposed, and the ligature applied, avoiding the vein which 
lies to the outside (Fig. 257). 

The Internal Carotid Artery Surgical Anat- 
omy.— The beginning of the first portion of this vessel is 
quite superficial, contained, as it is, in the superior carotid 
triangle, and being on the same plane with, but behind, the 
external carotid (Fig. 255, 10). As it ascends it ap- 
proaches the vertebrae lying above on the pre-vertebral 
structures. Ligature just above the point of bifurcation may 
therefore be performed. Above the point where it is crossed 
by the stylo-hyoid and posterior belly of the digastric mus- 
cles, its relations are so complicated that any operation per- 
formed with a a view to apply a ligature will be attended by 
serious difficulties. 

Course. — From the point of bifurcation of the common 
carotid artery opposite the upper border of the thyroid 
cartilage, vertically upward to the carotid foramen in the 
petrous portion of the temporal bone. 

Surface marking Sterno-mastoid muscle. 

General relations. — In front — Skin, superficial fascia, 
platysma, deep fascia, sterno-mastoid, digastric, and stylo- 
hyoid muscles ; external carotid and occipital arteries ; 
hypoglossal nerve, and parotid gland. 



THE SUBCLAVIAN ARTERY. 513 

Behind Rectus anticiis major muscle, and superior 

laryngeal nerve. 

Outside Internal jugular vein and pneumogastric nerve. 

Inside Pharynx, tonsil, and ascending pharyngeal 

artery. 

Guide. — Inner edge of sterno-mastoid muscle. 

Structures to he avoided Internal jugular vein, external 

carotid artery, and pneumogastric nerve. 

Operation The operation for applying the ligature to 

the artery just above the point of bifurcation is the same as 
that performed in ligaturing the external carotid at this 
point. The incision should be made along the anterior 
edge of the sterno-mastoid muscle, somewhat to the outside 
of that made in securing the external carotid, owing to the 
position of the internal behind the external carotid. 

The Subclavian Artery Surgical Anatomy 

This vessel, on the right side, arises from the innominate 
artery behind the sterno-clavicular junction, and ascends 
obliquely outward to the inner borcjer of the scalenus anticus 
muscle ; outward, behind the muscle, and from the outer 
border obliquely outward and downward beneath the clevicle 
to the lower border of the first rib, terminating in the 
axillary artery (Figs. 258, 259). On the left side it takes 
origin from the transverse portion of the arch of the aorta, 
and ascends almost vertically to the inner border of the 
scalenus anticus muscle, taking then the same course as on 
the right side. The scalenus anticus muscle therefore divides 
it into three parts ; the first lying to the inner side, the second 
behind, and the third extending from the outer side to the 
lower border of the first rib. 

Ligature of the first and second parts is very rarely 



514 



LIGATURE OF ARTERIES. 



practised ; the branches given off from the first part render 
the operation extremely hazardous, as well as prevent com- 



Fiff. 258. 




The Axillary and Subclavian Arteries. 

1. Clavicle cat across. 

2. Pectoralis major muscle partially cut away. 
3 Trapezius muscle. 

4. Sterno-cleido-mastoid. 

5. Omo-byoid. 

6. Deltoid. 

7. Pectoralis minor. 

8. The axillary artery. 

9. The axillary vein. 

10. The brachial plexus, above and behind. 

11. Supra-scapular artery. 

12. Cephalic vein passing in inter-space between deltoid and pectoralis major 
muscles to enter into axillary vein just above upper border of pectoralis minor 
muscle. 

13. External jugular vein. 




THE SUBCLAVIAN ARTERY. 515 

plete interference with the circulation by means of the 
ligature. If it should become necessary, it can be reached 
by the same incision as is made in ligaturing the innominate 
artery. 

The second part lies deeply behind the muscle, and offers 
no advantage over the third part, which is readily reached. 

The third part has no branches, and is placed in a trian- 
gular space formed above by the posterior belly of the omo- 
hyoid muscle ; below by the clavicle, 
and to the inner side by the sterno- ^^°' ' 

mastoid muscle. The size of this 
space is increased or diminished by 
the extent of attachment of the sterno- 
mastoid and trapezius muscles to the 

clavicle, the proximity of the posterior The Subclavian Artery. 

belly of the Omo-hyoid to the border l- Subclavian artery. 

„ , 1.1 T 1 • • f 2. Subclavian vein. 

or the clavicle, and the position or 3. First rib. 

the shoulder, whether depressed or 4. Scalenus anticus mus- 

1 , J T ii_ • ...1 J. cle, between vein and ar- 

elevated. In this space the artery ^^^.^ 
has important relations with the sur- 
rounding structures. The subclavian vein lies beneath the 
clavicle at this point of its course ; occasionally it rises into 
this space, and is in relation in front. The brachial plexus 
of nerves lies above and in close relation to the artery; the 
supra-scapular vessels pass transversely across the space near 
the margin of the clavicle ; the transverse cervical nerves 
cross its upper angle ; the external jugular vein passes down 
the neck along the posterior border of the sterno-mastoid, 
and empties into the subclavian vein ; it receives superficial 
veins, which lie in front of the artery. 

It is important to note the height to which the artery in 
its course rises in the neck. Normally, it may be said to 



516 LIGATURE OF ARTERIES. 

extend to the height of one-half of an inch above the clav- 
icle ; occasionally to the extent of an inch and a half, and 
sometimes its position is on a level with the upper border of 
the bone. Its relations with regard to the scalenus anticus 
also vary ; it has been found to pass in front or through the 
fibres of this muscle, and the vein is noted to have passed 
behind the muscle with the artery. 

Course — Right suhcJavian. — From the sterno-clavicular 
junction to the lower border of the first rib, obliquely up- 
ward, then outward and downward. 

Left suhcJavian From opposite the second dorsal ver- 
tebra to the lower border of the first rib almost vertically 
upward, then outward and downward. 

Surface marJcings. — Posterior border of the sterno-mas- 
toid muscle, anterior border of the trapezius muscle, upper 
border of the clavicle, possibly posterior belly of the omo- 
hyoid muscle. 

Relations at point of ligature Third portion. — In front. 

— Skin, superficial fascia, platysma muscle, deep fascia ; 
external jugular, suprascapular, and transverse cervical 
veins ; branches of cervical plexus of nerves, suprascapular 
artery, subclavius muscle, and clavicle. 

Behind Middle scalenus muscle. 

Above. — Brachial plexus of nerves and posterior belly of 
the onio-hyoid muscle. 

Belov: — First rib. 

Guides in order from icithout inicard. — 1. Posterior belly 
of the omo-hyoid. 2. Brachial plexus. 3. Scalenus anti- 
cus muscle. -4. Tubercle on first rib. 

Structures to he avoided. — External jugular vein, supra- 
scapular artery, brachial plexus of nerves, subclavian vein. 

Oferatiox Depressing the shoulder, so as to enlarge 



THK SUBCLA.VIAN ARTERY. 



517 



the subclavian triangle, an incision extending along the 
upper border of tlie clavicle from the posterior border of the 
sterno-mastoid to the anterior border of the trapezius should 
be made, dividing the skin. The superficial fascia and 
platysma should be divided on the director. The external 
jugular vein, at the inner side of the wound, should be 
drawn aside ; if necessary to divide it, two ligatures should 
be applied, and the vein cut between. The borders of the 
sterno-mastoid and trapezius may require division to give 
space. Avoid the suprascapular artery, separate the layers 

Fig. 260. 




1. Brachial plexus of nerves. 

2. Subclaviaa artery. 

3. First rib. 

4. Scalenus anticus muscle. 

5. Posterior border of sterno-mastoid muscle. 



of deep fascia cautiously with the finger, grooved director, 
or handle of the knife, and seek for the omo-hyoid muscle ; 
avoid the brachial plexus above, and still further separate 
44 



518 LIGATURE OF ARTERIES. 

the fascia and seek for the scalenus anticus muscle, and 
trace it to its insertion in the tubercle on the first rib — to its 
outer side the artery croSvSes the rib, where it can be felt. 
Pass the ligature carefully from below upward (Fig. 260). 

The Axillary Artery Surgical Anatomy 

The axillary artery is a continuation of the subclavian, begin- 
ning at the lower border of the first rib, passing downward 
through the axillary space and terminating at the lower 
borders of the latissimus dorsi and teres major muscles in 
the brachial (Figs. 258, 261). 

The axillary space or axilla, through which the artery 
passes, is a conical-shaped cavity placed between the side 
of the chest above and the inner side of the arm. Its 
boundaries are formed by the pectoralis major and minor in 
front, the subscapularis, the latissimus dorsi and the teres 
major behind, the four upper ribs, intercostal muscles and 
part of the serratus magnus muscle on the inside, and the 
humerus, coraco-brachialis, and biceps muscles on the out- 
side. This space contains important structures, in close 
relation ; the axillary vessels and brachial plexus of nerves 
with their branches, also branches of the intercostal nerves 
with lymphatic glands (ten or twelve in number), all held 
together by a quantity of fat and areolar tissue. A prolon- 
gation of the costo-coracoid membrane surrounds, to a 
greater or less extent, the vessels and nerves, forming a 
sheath for them. 

The course of the artery through this space varies accord- 
ing to the position of the arm. When the arm is placed in 
contact with the side of the chest, the artery is gently 
curved, the convexity looking upward and outward. With 
the arm at right angles to the body, it passes in a direct line. 



THE AXILLARY ARTERY. 



519 



and the arm being extended it assumes a curve, the con- 
vexity of which looks downward. It passes from the apex 



Fiff. 261. 




Axillary Artery below Pectoralis Minor Muscle. 

1. Pectoralis major muscle drawn upward. 

2. Pectoralis minor. 

3. Lattisimus dorsi and teres major muscles. 

4. Biceps muscle. 

5. Triceps muscle. 

6. Deep fascia of the arm. 

7. Axillary Artery. 

8. Brachial artery. 

9. Coraco-brachialis muscle. 

10. Musculo-cutaaeous nerve. 

11. Median nerve. 

12. Internal cutaneous nerve. 
1.3. Ulnar nerve. 

14. Axillary vein. 

1.). Lymphatic gland. 

16. Subscapular and inferior thoracic vessels. 



520 LIGATURE OF ARTERIES. 

to the base of the axilla nearer the anterior than the poste- 
rior wall, and is divided into three parts by the pectoralis 
minor muscle, the first portion extending from the lower 
border of the first rib to the upper border of the muscle, 
the second lying behind it, and the third terminating at the 
insertion of the latissimus dorsi and teres major muscles. 
Ligature can be performed in either the first or third por- 
tion ; the second portion is quite inaccessible, on account of 
its position behind the pectoralis minor muscle, and its 
relations are complicated by being embraced by the roots of 
the median nerve which arise from the inner and outer cord 
of the plexus, and unite either in front or on the outside of 
the artery. When selection is permitted, the third part is 
chosen as easier of access and freer from complications. 

Ligature in the First Portion Course From 

lower border of first rib to upper border of the pectoralis 
minor muscle. 

Surface marking Lower border of clavicle. 

Relatioris at point of ligature In front. — Pectoralis 

major muscle, costo-coracoid membrane, cephalic vein. 

Behind First intercostal space and muscle, second 

serration of serratus magnus muscle, posterior thoracic 
nerve. 

Inside Axillary vein. 

Outside. — Brachial plexus of nerves. 

Guides Pectoralis major muscle, deeper, pectoralis 

minor muscle, and costo-coracoid membrane. 

Structures to he avoided. — Superficially, cephalic vein and 
thoracico-acromialis artery ; deeper, axillary vein and 
brachial plexus of nerves. 

Operation. — The arm and the shoulder being drawn 
back, an incision three inches in length, one-half of an inch 



THE AXILLARY ARTERY. 



521 



below the clavicle and parallel to it, extending from the 
sternum to the edge of the deltoid muscle, should be made, 
dividing the skin. The superficial and deep fascia should 
be divided on the director, exposing the pectoralis major 
muscle. Divide the fibres of the clavicular portion of the 
muscle to the same extent as the external incision, and care- 
fully incise the areolar tissue which lies below. Seek the 
upper border of the pectoralis minor muscle, and cautiously 
open the costo-coracoid membrane. Relax the pectoralis 
minor muscle by bringing the arm to the side, and separate, 
with the grooved director, the artery carefully from the vein 
and other structures, and pass the ligature needle from within 
outward, carefully avoiding the vein (Fig. 262). 

Fig. 262. 




1. Axillary artery. 

2. Axillary vein. 

3. Brachial plexus of nerves. 



The artery can be reached, if necessary, in the second 
part by extending the incision downward. 

Ligature in the Third Portion Course — From the 

lower border of the pectoralis minor muscle to the lower 

44* 



522 



LIGATURE OF AKTERTES. 



borders of the latissinms dorsi and teres major muscles 
(Fig. 261). 

Surface marhings Borders of the axilla, head of the 

humerus, inner border of the eoraco-brachialis muscle. 

Relations at point of ligature In front Skin, fascia, 

and pectoralis major muscle. 

Behind. — Subscapularis, latissimus dorsi and teres major 
muscles, musculo-spiral and circumflex nerves. 

Inside Axillary vein, ulnar, and internal cutaneous 

nerves. 

Fig. 263. 




1. Axillary vein. 

2. Axilla 

3. Median nerve. 

4. Ulnar nerve — drawn aside. 

5. Internal cutaneous nerve. 

6. Axillary artery, 

7. Inner border of eoraco-brachialis muscle. 

OM<s«c?e.— Coracco-brachialis muscle, median and muf 
culo-cutaneous nerves. 

Guide. — Coraco-brachialis muscle. 



THE BRACHIAL ARTERY. 523 

Structures to be avoided Axillary vein, median and 

ulnar nerves. 

Operation Placing the arm at right angles to the 

body, make an incision two and one half inches in length 
over the course of the artery, at the point of junction of 
the anterior and middle thirds of the axilla, dividing the 
skin. Divide the fascia carefully on the grooved director, 
separate the areolar tissue with the finger or handle of the 
knife, and seek the axillary vein to the inside and median 
nerve to the outside. Flex the arm so as to relax the vein 
and nerve, isolate the artery carefully, and pass the ligature 
needle from within outward (Fig. 263). Note a muscular 
slip from the latissimus dorsi muscle which occasionally 
crosses the artery at this point, which may mislead. The 
transverse direction of its fibres can be recognized. 

The Brachial Artery Slrgical Anatomy This 

artery begins at the lower border of the tendons of the 
latissimus dorsi and teres major muscles, and passes down 
on the inner and anterior surface of the arm, terminating 
about one-half of an inch below the bend of the elbow in 
the radial and ulnar arteries (Fig. 264). A line drawn from 
the point of junction of the anterior and middle thirds of 
the axilla to a point midway between the condyles, will 
indicate its course. As it descends it winds around the 
bone, passing from the inner to the anterior surface. For 
the purposes of ligature, it may be divided conveniently 
into two parts, that lying above the point at which the 
median nerve crosses it, which may be designated as the 
middle of the vessel, and that below this point. In the 
upper part, the nerve lies to the outer side of the artery in 
close contact ; as it descends it passes very obliquely in 



524 



LIGATURE OF ARTERIES. 



Fig. 264. 




The Brachial Artery. 



front, and occasionally be- 
hind, and takes a position to 
the inner side. The artery 
also presents a number of 
peculiarities as to course, 
point of bifurcation, and 
muscular relations which 
should be considered by the 
surgeon. 

Its course down the arm 
may be varied by a depart- 
ure from the inner border of 
the biceps muscle to the in- 
ner condyle of the humerus, 
and then to the bend of the 
elbow, passing through the 
pronator radii teres muscle. 
Irregularity with regard to 
the point of bifurcation is of 
rather frequent occurrence ; 
it occurs more frequently in 
the upper than in the middle 
or lower part of the arm — 

1, 2. The brachial artery. 

3. Coraco-brachialis muscle. 

4. Biceps muscle. 

5. Median nerve, crossiug the artery. 

6. 7. Venae comites. 

8. Inferior profunda artery. 

9. Ulnar nerve. 

10. Bicipital fascia, beneath which the 
artery passes. 

11. Median basilic vein separated from 
the ariery by bicipital fascia. 



THE BRACHIAL ARTERY. 525 

in three out of four cases it takes place as a high division of 
the radial, which arises from the inner surface of the bra- 
chial, and passes down the arm parallel with the main trunk 
to the elbow, where it crosses the artery to the outside. In 
these cases, two large vessels would be found, which should 
be carefully examined, in order to decide to which one the 
ligature should be applied. 

Occasionally it is found that muscular layers passing be- 
tween the coraco-brachialis and triceps muscles, and between 
the other muscles, have covered the artery for some distance 
in its course ; these must be divided, in order to reach the 
vessel. 

Course From the lower margin of the teres major 

muscle to one-half of an inch below the bend of the elbow. 
A line drawn from the point of junction of the anterior and 
middle thirds of the axilla to a point midway between the 
condyles, will indicate its course. 

Surface markings Inner border of the coraco-brachi- 
alis and biceps muscles. 

General relations In front — Skin and fascia, median 

nerve, and median basilic vein. 

Behind Triceps, coraco-brachialis, and brachialis anti- 

cus muscles ; musculo-spiral nerve, and superior profunda 
artery. 

Inside Internal cutaneous, ulnar, and median nerves. 

Outside Median nerve, coraco-brachialis and biceps 

muscles. 

Guides. — Inner border of coraco-brachialis and biceps 
muscles. 

Structures to he avoided. — Median nerve, possibly ulnar 
nerve, and superior profunda artery; internal cutaneous 
nerve and basilic vein. 



526 LIGATURE OF ARTERIES. 

Operation Above the point at which the median nerve 

crosses the arteiy. 

The arm being drawn from the side, and the hand supi- 
nated, an incision from two to three inches in length should 
be made along the inner border of the coraco-brachialis mus- 
cle, dividing the skin. The superficial and deep fasciae 
should be divided carefully on the director, care being taken 
to avoid the internal cutaneous nerve. The artery, accom- 
panied by venae comites, will be found lying along the bor- 
der of the coraco-brachialis muscle ; the internal cutaneous 
and ulnar nerves and basilic vein being to the inner, and 
the median nerve to the outer side. Separate the venae 
comites, and pass the ligature-needle from witliin outward, 
avoiding the vein. 

Operation — Below the point at which the median nerve 
crosses the artery. 

The arm being in tlie same position as in the operation 
just described, an incision from two three inches is made 
directly over the inner border of the biceps muscle, dividing 
the skin. The superficial and deep fasciae are very carefully 
divided, in order to avoid the basilic vein, which at this 
point is superficial. The median nerve is now seen as a large 
white cord lying to the inside of the artery. Flex the arm 
so as to relax the biceps and median nerve, and separate the 
venae comites from the artery. Pass the ligature-needle 
from within outward (Fig. 265). 

In this operation the attention of the surgeon is directed 
to the position of the artery, median nerve, and ulnar nerve, 
and their relation to each other. The artery, at this point, 
lies in very close contact with the border of the biceps, the 
median nerve separated slightly to the inner side, and 
the ulnar nerve removed some distance from the median. 



BRACHIAL ARTERY AT THE BEND OF THE ELBOW. 527 

and passing inward and backward. If the incision is made 
too far from the inner border of the biceps muscle, the ulnar 
nerve may be mistaken for the median, and thus confusion 
arise. This error can be avoided by keeping near to the 
border of the biceps muscles and bearing in mind the order 

Fig. 265. 




1. Vense comites. 

2. Mediaa nerve. 

3. Brachial artery. 

4. Biceps muscle. 



of relation from without inward, which is as follows ; inner 
edge of biceps — artery in close contact ; median nerve 
slightly separated from artery ; ulnar, separated to some dis- 
tance from median nerve (Fig. 264). 



The Brachial Artery at the Bend of the 

Elbow Surgical Anatomy At this point the artery 

occupies a position beneath the tendon of the biceps in a 
triangular space formed by the supinator longus muscle ex- 
ternally, the pronator radii teres internally, the floor being 
formed by the brachialis anticus and supinator brevis mus- 
cles. 



528 



LIGATURE OF ARTERIES. 



Course Obliquely across the bend of the elbow from 

within outward. 

Surface markings Pronator radii teres and supinator 

longus. 

Relations. — In front. — Skin, fascia, median basilic vein, 
and bicipital fascia. 

Behind Brachialis anticus muscle. 

Inside Median nerve. 

Outside Supinator longus muscle. 

Guide. — Inner edge of tendon of biceps muscle. 

Structures to he avoided. — Median basilic vein ; median 
nerve. 

Operation. — Make an incision two and a half inches 
in length along the inner edge of the biceps tendon, the 

Fig. 266. 




1. Brachial artery. 

2. Median nerve. 

3. Tendou of biceps muscle. 

■1. Pronator radii teres muscle. 
6. Deep fascia. 



arm being extended and the hand supine, dividing the 
skin. Dividing the superficial fascia carefully, so as to 
avoid wounding the superficial veins, the bicipital fascia is 
exposed. Incise this and seek for the artery, surrounded 



THE RADIAL ARTERY. 



529 



by the venns comites, beneath 
and lying between tlie tendon 
of the biceps muscle on the 
outside and the median nerve 
on the inside. Pass the liga- 
ture-needle from the median 
nerve (Fig. 266). 

The Radial Artery 

Surgical Anatomy The 

radial artery, the smaller of 
the two vessels into which the 

L Brachial artery. 

2. 2. Radial and ulnar arteries at 
point of bifurcation, 

3. Ulnar artery, middle third. 

4. Ulnar artery, lower third. 
0. Superficial palmar arch. 

6. Radial artery, middle third. 

7. Radial artery, lower third. 
Median nerve. 
Median basilic vein. 
Bicipital fascia. 
Median nerve crossing ulnar ar- 



Fig. 267. 



8. 

9. 
10 
11. 
tery. 
12. 
13. 



Ulnar nerve. 

Tendon and muscle of flexor carpi 
ulnaris. 

14. Inner tendon of the flexor subli- 
mis digitorum. 

15. Sapinator longus muscle. 

16. Pronator radii teres muscle cut 
through. 

17. Superficial flexor muscle cut 
through, showing ulnar artery and 
median nerve. 

IS. Beginning of tendon of supinator 
longus muscle. 

19. Radial nerve. 

20. Venae comites. 

45 




The Radial and Ulnar Arte 



530 LIGATURE OF ARTERIES. 

brachial divides, passes from its point of origin, opposite the 
coronoid process of the ulna, downward and outward along 
the radial side of the forearm to the wrist. In its course it 
passes from the inside of the radius above to the front of the 
bone below. A ligature may be applied at any part of its 
course in the upper, middle, or lower third (Fig. 267). 

Gjurse — A line drawn from the middle of the bend of 
the elbow to the front of the styloid process will represent 
its course. 

Surface ynarhing, — Inner border of the muscle and ten- 
don of the supinator longus. 

General relations In front Skin, superficial and deep 

fasciae, supinator longus muscle. 

Behind Tendon of biceps muscle, supinator brevis, 

pronator radii teres, flexor sublimis digitorum, flexor longus 
pollicis, pronator quadratus muscles, and the radius. 

Inside — Pronator radii teres muscle, flexor carpi radialis 
muscle, and tendon. 

Outside. — Supinator longus muscle and tendon. 

Guide Supinator longus muscle and tendon. 

Structures to be avoided. — Median vein and radial nerve. 

Operation. — In the dipper third An incision, from two 

to three inches in length, dividing the skin and carefully 
avoiding the median vein, is made from the bend of the 
elbow obliquely downward and outward in the groove which 
marks the line of separation between the supinator longus 
and pronator radii teres muscles. The superficial and deep 
fascioe are divided on the director. Flexing the arm slightly, 
so as to relax the muscles, the supinator longus is drawn 
aside, and the artery, in its sheath with the venae comites, 
will be exposed, the radial nerve lying to the outside. Sepa- 



THE RADIAL ARTERY. 



531 



rating the venae coniites, the ligature needle is passed from 
without inward (Fig. 268). 



Fig. 268. 




1. Supinator lonofus musclo. 

2. Radial artery. 

In the middle third — The artery can be exposed by an 
incision two inches in length along the inner border of the 
supinator longus 



muscle, dividing the 
skin. The fasciae 
being divided, the 
artery is found, with 
the radial nerve in 
close contact, on the 
outside. Pass the 
ligature needle from 
the nerve. 

In the lower third. 
— At this point the 
artery lies super- 
ficial between the tendons of 



Fig. 269. 




1, Deep fascia. 

2, 4. Venae comites. 

3, Artery. 



the supinator longus and 



flexor carpi radialis, the nerve being some distance to the 



532 



LIGATURE OF ARTERIES. 



Fig. 270. 



outside, leaving the artery about three inches above the 
wrist. Fix the position of the tendon of the flexor carpi 
radialis muscle by manipulating the hand, and make an 
incision one inch and a half along its external border, divid- 
ing the skin. Divide the fasciae on the director, and thus 
expose the sheath of the vessel. 
Open the sheath, separate the artery 
from the venae comites, and pass the 
ligature needle from without inward 
(Fig. 269). 

On the Outer Side of the 

Wrist. — Surgical Anatomy 

The artery, as it crosses to the outer 
side of the wrist to pass into the 
hand, lies beneath the extensor ten- 
dons of the thumb, in a space known 
as the "snuff-box" (Fig. 270). 
Here it can be ligatured by making 
an incision, which divides the skin, 
one inch and a quarter in length, 
beginning opposite the styloid pro- 
cess of the radius and terminating 
at the first interosseous space. 
Dividing the fasciae on the director, 
seek the tendon of the extensor 
secundi internodii pollicis muscle, 
which crosses the artery just before 
it passes into the palm of the hand, 
and furnishes a guide to the vessel. 
Apply the ligature to the artery on 
the ulnar side of the tendon, avoiding the veins and a small 
branch of the musculo-cutaneous nerve which accompanies it. 




Radial Artery on the outer 
side of tlie Wrist 

1. Posterior annular liga- 
ment of the carpus. 

2. Tendon of extensor ossis 
inetacarpi pollicis. 

3. Tendon of extensor primi 
internodii pollicis. 

4. Tendonoftheextensor se- 
cundi internodii pollicis. 

5. Radial artery. 



THE ULNAR ARTERY. 533 

The Ulnar Artery Surgical Anatomy — This 

vessel, the hirger of the two terminal branches of the 
brachial artery, begins at the point of bifurcation opposite 
the coronoid process of the ulna, and crosses obliquely to the 
inner side of the forearm, which it reaches about the middle, 
then descends along the ulnar border to the wrist, terminat- 
ing in the superficial palmar arch. A line drawn from the 
internal condyle of the humerus to the outer side of the pisi- 
form bone, will indicate its course in the lower half. Liga- 
ture in the upper portion is rarely performed, owing to the 
position of the vessel beneath the superficial flexor muscles, 
which must be divided in order to apply the ligature. In a 
preparation, in possession of the author, the arteries of both 
sides pass above the superficial flexor muscles, a high bifur- 
cation occurring on the left side, the right ulnar being given 
off" from the lower portion of the axillary. In the middle 
part it is slightly covered by the tendons of the flexor carpi 
ulnaris and the inner tendon of the flexor sublimis digitorum. 
In the lower part it is superficial. The median nerve crosses 
it obliquely just below its point of origin, while the ulnar 
nerve comes into close relation with it at the lower part of 
the upper half (Fig. 267). 

Course. — From the bend of the elbow to the radial side 
of the pisiform bone. 

Surface marking Muscle and tendon of the flexor carpi 

ulnaris. 

General relations In front Upper half — Superficial 

flexor muscles and median nerve. 

Lower half — Superficial and deep fasciae. 

Behind — Brachialis anticus and flexor profundus digito- 
rum muscles. 

45* 



534 



LIGATURE OF ARTERIES. 



Inside — Flexor carpi ulnaris muscle and, in lower two- 
thirds, ulnar nerve. 

Outside. — Muscle and tendons of the flexor sublimis digi- 
torura. 

Guide Muscle and tendon of the flexor carpi ulnaris. 

Structures to he avoided Ulnar nerve and venae comites 

in upper half; median nerve. 

Operation. — In upper half. — An incision should be made 
starting two and one-half inches below the internal con- 
dyle of the humerus, and one-quarter of the width of the arm 
from the inner edge, extending downward to the extent of 
three inches, dividing the skin. The fasciae being divided, 
seek the white, pearly aponeurotic line marking the septum 
between the flexor carpi ulnaris muscle on the inside, and 
the flexor sublimis digitorum on the outside. Incise this 
septum to the same extent as the incision through the skin 




/ 23 V -^ 

1. Flexor sublimis muscle. 

2. Ulnar nerve. 

3. Flexor profundus muscle. 

4. Venae comites. 

5. Ulnar artery. 



and fasciae. Flex the arm, and separate with the finger the 
superficial muscles from the flexor profundus digitorum. 



THE ULNAR ARTERY. 



53o 



Seek the artery lying on this muscle with the ulnar nerve 
to the inside. Pass the ligature-needle from the nerve 
(Fig. 271). 

In ligaturing the vessel at this point the surgeon should take 
especial care in seeking for the septum which separates the 
flexor carpi ulnaris from the flexor sublimis digitorum mus- 
cle, and which is to be divided in preference to the muscular 
substance. It will be recognized as a white, orlistenino; 
membrane, the fibres of which are parallel with the fibres of 
the muscles. 

In middle of the forearm The artery can be reached by 

an incision three inches in length alono- the external border 
of the flexor carpi ulnaris, dividing the skin. The fasciee 
being divided, the flexor carpi ulnaris and the inner tendon 




1. Flexor carpi ulnaris muscle. 

2. Vena; comites. 

3. The integuments. 

4. Ulnar artery. 

5. Deep fascia. 



of the flexor sublimis digitorum should be separated, exposing 
the artery with the ulnar nerve to the inside in close rela- 
tion. Pass the ligature-needle from the nerve, avoiding the 
venae comites. 



536 LIGATURE OF ARTERIES. 

In lower half, — An incision two inches in length is made 
along the outer edge of the tendon of the flexor carpi ulnaris 
muscle three-quarters of an inch from the ulnar border of 
the limb, dividing the skin. Divide the fasciae on the direc- 
tor, and, slightly flexing the hand, seek the artery covered 
by the tendon of the flexor carpi ulnaris and inner tendon 
of the flexor sublimis digitorum muscle. Separate the 
venae comites, and pass the ligature from within outward 
(Fig. 272). 

In this operation the surgeon is cautioned against making 
the incision too near the ulnar border of the limb. 

The Abdominal Aorta Surgical Anatomy 

The abdominal portion of the aorta is the continuation of 
the thoracic portion, beginning at the opening in the dia- 
phragm opposite the body of the last dorsal vertebra, de- 
scending on the left side of the vertebrae, and terminating 
on the left side of the fourth lumbar vertebra in the two 
common iliac arteries. Between the point of origin of the 
inferior mesenteric artery, a large branch, and the bifurca- 
tion of the aorta into the common iliac arteries, there are 
given off from the posterior surface several small branches, 
four lumbar from each side, and the sacra media. This 
portion of the vessel, therefore, presents itself as best 
adapted for the application of the ligature, as well for this 
reason as on account of its position rendering it easier of 
access. 

Course From the front of the body of the last dorsal 

vertebra downward on the left side of the vertebral column 
to the left side of the body of the fourth lumbar vertebra at 
the point of bifurcation. 

Surface marking The linea alba. 



THE ABDOMINAL AOKTA. 537 

Relations at point of ligature. — In front. — The Btructures 
forming the abdominal wall, transverse colon, omentum, 
and mesentery ; convolutions of the small intestines, peri- 
toneum. 

Behind Left lumbar veins and vertebrise. 

Right side Inferior vena cava. 

Left side — Sympathetic nerve. 

Guide — Vertebral column. 

Structures to he avoided Inferior vena cava, sympa- 
thetic nerve. 

Operation The vessel can be reached by two methods 

of operation. 

1. By an incision three inches in length through the skin, 
beginning one and a half inch above umbilicus in the linea 
alba. Carrying the incision around umbilicus, divide the 
structures on the director until the peritoneum is reached ; 
incise this on the director, thus opening the abdominal 
cavity. Raise the omentum, and push the intestines to the 
right side. Seek the aorta on the left side of the lumbar 
vertebrae, and carefully tear through the peritoneum cover- 
ing the vessel. Pass the ligature from the right to the left, 
avoiding the vena cava. 

2. An incision should be made on the left side of the 
body from the end of the eleventh rib to the crest of the 
ilium, dividing the common integuments. The layers of 
muscles, external and internal, oblique and transversalis, 
and transversalis fascia, should be carefully divided on the 
director. Cautiously push off the posterior layer of the 
peritoneum until the aorta is uncovered, and pass the liga- 
ture as in the first method. 

The advantage this method has over the first, is in pre- 
serving the integrity of the peritoneum. On the other 



538 



LIGATURE OF ARTERIES. 



hand, the operation by the second plan involves the 
wounding of the muscular structures, and separation, to 
some extent, of the peritoneum from the underlying struc- 
tures. 



The Common Iliac Artery. — Surgical Anatomy. 

■The common iliac arteries, terminal branches of the aorta, 

begin at the point of 
Fig- 273. , . ° . '^^ , ,. 

*=" bifurcation on the left 

side of the body of the 
fourth lumbar verte- 
bra, and pass down- 

..7 1. Sectioa of the muscles of 

../^ the abdomen at their insertion 

— /o into crest of the ilium. 

--ih 2. Superior spinous process 

■/ of the ilium. 

'^^ 3. Fascia lata of the thigh. 

4. Psoas muscle, 
fl. Iliacus iuternus muscle. 

6. Aorta. 

7. Right common iliac ar- 
tery. 

5. External iliac artery. 
9. Internal iliac artery. 

10. Iliac vein. 

11. Inferior vena cava. 

12. Anterior crural nerve. 

13. Lymphatic glands. 

14. Speimatic vessels. 

1.5. Circumflex iliac artery. 
The Common, External, and Internal Iliac 16. The ureter. 

Arteries. 17. The epigastric artery. 




ward and outward to the margin of the pelvis. Opposite 
the intervertebral substance, between the last lumbar verte- 
bra and the sacrum, they divide into the external and inter- 
nal iliac arteries. The point of bifurcation of the aorta cor- 



THE COMMON ILIAC ARTERY. 539 

responds to a point to tlie left of the umbilicus, and on a 
level with a line passing between the highest points on the 
crests of the ilia (Fig. 273). 

It is to be noted that these vessels lie beneath the peri- 
toneum, and that the relation of the vein on the right and 
left vside differs, being behind and external on the right'side, 
and behind and internal on the left. High up, the left vein 
passes behind the right common iliac artery to join tlie right 
vein in forming the inferior vena cava. Peculiarities with 
regard to point of origin, point of division, and relative 
length are frequently observed, and sliould be borne in 
mind. 

Course. — From bifurcation of aorta on left side of body 
of fourth lumbar vertebra, downward and outward to oppo- 
site tlie intervertebral substance between last lumbar verte- 
bra and sacrum. A line drawn from the left side of the 
umbilicus to the middle of Poupart's ligament indicates the 
course. Length of the vessel, two inches. 

Relations at point of ligation — Right common iliac ar- 
tery. — In front. — Peritoneum, ileum, branches of sympa- 
thetic nerve; at the point of bifurcation into the external 
and internal iliac arteries, it is crossed by the ureter. 

Behind. — The two common iliac veins. 

Outside. — Inferior vena cava, right common iliac vein ; 
psoas magnus muscle. 

Left common iliac artery. — In front Peritoneum, 

branches of sympathetic nerve, rectum, superior hemor- 
rhoidal artery ; at bifurcation, crossed by left ureter. 

Behind. — Left common iliac vein. 

Inside. — Left common iliac vein. 

Outside — Psoas magnus muscle. 

Guide. — Sacro-iliac articulation. 



540 LIGATURE OE^ ARTERIES. 

Structures to be avoided. — -Common iliac veins, ureters, 
sympathetic nerve, inferior vena cava, peritoneum. 

Operation An incision, in a direction outward to the 

anterior superior spine of the ilium, from six to eight inches 
in length, should be made two inches above and parallel to 
Poupart's ligament, beginning at the junction of the inner 
and middle third of the space between the symphysis pubis 
and the anterior superior spine of the ilium, dividing the 
skin. The superficial and deep fascise, tendon of the exter- 
nal oblique muscle, the internal oblique and transversalis 
muscles are to be carefully divided on the director, layer 
after layer, until the transversalis fascia is exposed. The 
edges of the wound should be separated by retractors, the 
transversalis fascia gently raised and scratched through, 
making an opening, into which the point of the director can 
be introduced. Making sure, by careful examination, tlxat 
the director is between the fascia and the peritoneum, and 
not beneath the latter, the fascia should be divided. The 
peritoneum is now gently pushed off to a sufficient extent to 
enable the artery to be brought into view at the sacro-iliac 
junction. Opening carefully, with the finger nail, or with 
the point of the director, the aheath of the vessel, and sepa- 
rating the vein from the artery, the ligature is to be passed 
from the former. 

The External Iliac Artery.— Surgical Anat- 
omy. — The external iliac artery is the larger of the two 
terminal branches of the common iliac, and passes from the 
point of bifurcation obliquely downward and outward along 
the inner border of the psoas magnus muscle to the crural 
arch. A line drawn from a point to the left of the umbilicus, 
to a point midway between the anterior posterior spinous 



THE INTERNA] 



LI AC ARTERY. 



541 



Fis. 274. 



process and the symphysis pubis, will indicate its course 
(Fig. 273). 

Course Obliquely downward and outward across the 

pelvic cavity to the crural arch. 

Relations at the point of ligature — In front. — Peritoneum, 
intestines, iliac fascia, spermatic vessels, genito-crural nerve, 
circumflex iliac vein, 
lymphatic vessels and 
glands. 

Behind. — External 
iliac vein. 

Inside. — External 
iliac vein and the vas 
deferens. 

Outside. — Psoas mag- 
nus muscle, iliac fascia. 

Guide. — Inner border 
of the psoas magnus 
muscle. 

Structures to be avoid- 
ed — External iliac vein, 
genito-crural nerve, peri- 
toneum. 

Operation. — This 
artery can be exposed 
by the same plan of operation as that employed in ligature 
of the common iliac artery (page 540). The incision need 
be but four inches in length, and not so far removed from 
the line of Poupart's ligament (Fig. 274). 




1. The interual obliriae aad trans vei'salis 
muscles. 

2. The external iliac artery. 

3. The external oblique muscle. 

4. The peritoaoura. 



The Internal Iliac Artery Surgical Anatomy. — 

The internal iliac artery, tlie smaller of the terminal branches 
4G 



642 LIGATURE OF ARTERIKS. 

of the common iliac, is a short brancli measuring about an 
inch and a half in length (Fig. 273). It presents peculi- 
arities, as to length and point of division, which should be 
noted. 

Course. — From the point of bifurcation of the common 
iliac, downward to the upper margin of the great sacro- 
sciatic foramen. 

General relations, — -Tn front. — Peritoneum, ureter. 

Behind. — Internal iliac vein, lumbo-sacral nerve, piri- 
formis muscle. 

Outside Psoas magnus muscle. 

Guide Inner border of the psoas magnus muscle. 

Structures to he avoided Internal iliac vein and ureter, 

peritoneum. 

Operation. — This vessel can be surrounded by a liga- 
ture by the same method as that described for tying the 
external iliac artery (Fig. 274). 

In performing operations for the ligature of the iliac 
arteries, careful attention should be given to the relations 
of the large venous trunks which accompany them. These 
vessels lie in close contact with the arteries, their walls are 
delicate and thin, and they receive numerous branches 
from the different parts of the pelvic cavity. Great care 
should be exercised in using instruments to displace them 
or to separate them from the arteries. The position of 
the ureters should also be carefully considered. Being 
closely united to the peritoneum, they are usually lifted 
with that structure when it is detached to expose the 
vessels. In persons of advanced age, the peritoneum is 
frequently found quite adherent to the underlying tissues, 
and therefore difficult to separate. In these cases, unless 
great caution be observed, this membrane may be lacerated. 



THE SCIATIC ARTERY. 543 

The Gluteal Artery Sirgical Anatomy. — The 

gluteal artery, tlie largest branch of the internal iliac, is 
given off from the posterior trunk, and passes out of the 
pelvic cavity throush the great sacro-sciatic foramen above 
the upper bonier of the pyriformis muscle. 

Course A line drawn from the posterior superior spine 

of the ilium to the top of the great trochanter, indicates 
the course of the artery after its emergence from the pelvic 
cavity. 

General relations. — Outside Skin, superficial and deep 

fasciiB, gluteus maximus muscle. 

Inside Gluteus minimus muscle. 

Above Gluteus medius muscle. 

Below Pyriformis muscle. 

Guides. — Pyriformis and gluteus medius muscles. 

Structures to he avoided Gluteal vein and superior 

gluteal nerve. 

Operation The patient being placed on his abdomen, 

an incision, five inches in length, is made over the course 
of the artery, dividing the skin. The superficial and deep 
fasciae are divided on the director, exposing the gluteus 
maxiraus muscle. The fibres of this muscle should be 
separated, and the artery sought for as it emerges from 
the pelvic cavity above the upper border of the pyriformis 
muscle, and the ligature applied, carefully avoiding the 
veiDS and nerves. 

The Sciatic Artery Slrgical Anatomy. — The 

sciatic artery is the larger of the two terminal branches of 
the anterior trunk of the internal iliac, and escapes from 
the pelvic cavity through the lower part of the great sacro- 
sciatic foramen. 



544 LIGATURE OF ARTERIES. 

Course.— After emerging from the pelvic cavity through 
the lower part of the great sacro-sciatic foramen between 
the pyriformis and coccygeus muscles, it passes downward 
in the interval between the trochanter major and tuberosity 
of the ischium. The point of exit from the pelvic cavity 
is indicated by the centre of a line drawn from the poste- 
rior superior spinous process of the ilium to the tuberosity 
of the ischium. 

delations Outside. — Skin, superficial and deep fasciae, 

and gluteus maximus muscle. 

Inside. — Gemellus superior and obturator internus mus- 
cles. 

Above. — Pyriformis muscle. 

Below. — Coccygeus muscle. 

Guide Coccygeus muscle and lower border of the pyri- 
formis muscle. 

Structures to be ai^oided. — Internal pudic artery, sciatic 
nerve and vein. 

Operation.— The patient being placed upon the abdo- 
men, an incision three inches in length is made over the 
point of exit of the artery from the pelvic cavity, in the 
line given to indicate this point, dividing the skin. The 
superficial and deep fascijB should be divided, exposing the 
fibres of the gluteus maximus muscle. Separate the fibres 
of this muscle, and seek the artery as it appears between 
the coccygeus and pyriformis muscles. Pass the ligature, 
carefully avoiding the nerve and vein. 

The Internal Pudic Artery Surgical Anat- 
omy. — This artery is the smaller of the two terminal 
branches of the anterior trunk of the internal iliac. As it 
escapes from the pelvic cavity by the same opening as the 



THE FEMOUAL ARTERY. 



545 



sciatic artery, its course and relations at the point of ligature 
are essentially the same, and it may be secured by a similar 
plan of operation. 



The Femoral Ar- 
tery. — Surgical 
Anato^iy . — The fe- 
moral artery is the con- 
tinuation of the external 
iliac, and passes down- 
ward on the anterior and 
inner aspect of the thigh 
from the crural arch to 
the junction of the mid- 
dle with the lower third 
of tlie thigh, where it 
enters an opening in the 
adductor magnus muscle 

1. Poupart's ligament. 

2. Aponeurosis formiog Hau- 
ter's canal. 

3. Anterior crural nerve. 

4. Femoral artery. 
5 Femoral vein. 

6. Long saphenous nerve. 

7, 7. Sartorius muscle, drawn 
to the outside. 

5. Internal saphenous vein. 
9. Profunda femoris artery. 

10. Branch of anterior crural 
nerve, lying in front of the 
femoral sheath. 

11. Another branch which 
passes across the vessels to 
join the internal saphenous 
vein. 

12. 12. Musculo-cutaueous 
branches. 



Fi^. 275. 




46* 



546 LIGATUKE OF ARTERIES. 

and becomes the popliteal (Fig. 275). The upper third of 
the vessel is superficial, and occupies a triangular space 
called " Scarpa's triangle." This triangle corresponds to 
the depression immediately below the fold of the groin, and 
is bounded by the sartorius muscle on the outside, the adduc- 
tor longus muscle on the inside, and Poupart's ligament 
above. The floor is formed by the iliacus, psoas, pectineus, 
adductor longus, and a part of the adductor brevis muscles, 
passing in order from without inward. 

The femoral vessels bisect this triangle as they pass from 
the middle of the base to 'the apex. Above, the artery 
lies on the inner border of the psoas magnus muscle, which 
separates it from the capsular ligament of the hip-joint. 
The artery and vein are inclosed in a strong fibrous sheath, 
the crural sheath, formed by the transversalis and iliac 
fasciae — the artery, to the outside, and the vein, to the in- 
side, separated by a septum. 

The anterior crural nerve lies to the outside of the com- 
mon sheath, to the distance of about one-half of an inch. 
The femoral vein above lies to the inner side of the artery ; 
a short distance below the origin of the profunda femoris it 
passes behind the artery, and in the lower third it is placed 
on the outside. 

The course the vein takes should be remembered, and 
its relations to the artery at the various parts of its course — 
inside, behind, and outside, in oider, from above downward. 

The internal saphenous nerve, the largest branch of the 
anterior crural, comes into immediate relation with the 
artery about the middle third, as it passes beneath the sar- 
torius muscle ; as it descends it gradually gets in front of 
the artery, crossing it as it enters Hunter's canal, and pass- 



THE FEMORAL ARTERY. ' 547 

iii"j to the inside of tlie thiirh. The nerve acts as a oruide to 

o c o 

the vessel as it passes into tliis canal. 

Hiinter^s canal^ from one to two inches in length, is 
described as being formed by a dense fibrous a[)oneurosis, 
extending from the tendons of the adductors longus and 
magnus downward and inward to unite with the tendinous 
origin of the vastus internus muscle. It is triangular in shape, 
and bounded externally by the vastus internus, and internally 
by the adductor longus and adductor magnus muscles. 

As the internal saphenous vein passes up the thigh to 
join the femoral, through the saphenous opening, it has 
an important relation to the points at which the incisions 
are made for exposing the artery in its lower and middle 
thirds, lying almost directly in the line of the incisions. 
The position of the vein should always be ascertained by 
making jiressure over its course above, and it should be 
drawn to the inside while the incision is being made. In 
its course it receives numerous branches, which join it from 
the outer and inner surfaces of the thigh. 

As ligation of the artery above the origin of the profunda 
femoris is not advised, it is important to determine the 
point at which this vessel is given off. Its normal point of 
origin is stated to be from one to two inches below Poupart's 
ligament, and from the outer and back part of the artery. 
Anomalies, with regard to its point of origin, are noted as 
occasionally occurring, the vessel being given off at or just 
below Poupart's ligament, and, in one instance, four inches 
below. In a case in which the author applied a ligature to 
the femoral artery ibr a punctured wound of tl\e lower 
third, the profunda artery wa« found to take origin from 
the external iliac just above Poupart's ligament. It should 
also be remembered that occasionally the artery divides into 



548 LIGATURE OF ARTERIES. 

two trunks below the origin of the profunda, and reunites 
before entering Hunter's canal. 

A rare anomaly with regard to the position of tlie 
femoral artery is noted, in which the vessel occurred as a 
branch of the internal iliac artery passed out of the pelvic 
cavity through the great sacro-sciatic foramen, and descended 
the thigh in its posterior aspect in connection with the 
great sciatic nerve. In the living subject, absence of pul- 
sation at the crural arch would suojgest the existence of such 
an anomaly. 

Course From a point midway between the anterior 

superior spinous process of the ilium and the symphysis 
pubis, down the front and inner side of the thigh, termin- 
ating at the opening in the adductor magnus muscle, this 
opening being at the junction of the middle with the lower 
third of the tliigh. A line drawn from the point midway 
between the anterior superior spinous process of the ilium 
and the symphysis pubis to the inner side of the inner con- 
dyle of the femur, will indicate its course. 

Surface marking Inner edge of the sartorius musle. 

General relations In front. — Skin, superficial and deep 

fasciae, and sartorius muscle. 

Behind. — Psoas, pectineus, adductor longus and tendon 
of adductor magnus muscles, femoral vein. 

Inside Femoral vein. 

Outside. — Anterior crural and internal saphenous nerves, 
vastus internus muscle. 

Guide — Inner border of the sartorius muscle. 

Structures to he avoided. — Internal saphenous and femoral 
veins, internal saphenous nerve. 

Common sheath. — Including artery and vein. 

Operation The common femoral, above the profunda 

femoris. 



THE FEMORAL ARTERY. 



549 



An incision two inclies in length is made over tlie course 
of the artery, beginning at a point midway between the 
anterior superior spinous process of the ilium and symphysis 
pubis, dividing the skin. The fascite are carefully divided 
on the director, and the sheath of the vessels exposed. Open- 
ing this to a slight 

extent, the vein jio- -.lu. 

is drawn inward, 
and the ligature 
needle passed 
from within out- 
ward (Fig. 274). 

In the opera- 
tion at this point, 
which is not ad- 
vised, owing to 
the number of 
branches here 
given off from the 




1. The deep fascia. 

2. The femoral artery. 

3. The femoral vein. 



artery, care 
should be taken 
to pass the liga- 
ture above the origin of the profunda femoris, and not 
immediately below it. This can be accomplished by bring- 
ing into view Poupart's ligament, and applying the ligature 
from three-quarters to one inch below. The fold of the groin 
should not be taken as a guide to the position of Poupart's 
ligament, as in those who are corpulent the fold is below 
the ligament, and not on a line with it. The arteiy may be 
reached at this point by an incision below and parallel to 
Poupart's ligament, across instead of parallel to tlie artery. 



550 



LIGATURE OF ARTERIES. 



Fig. 277. 



Operation — The superficial femoral artery at the apex 
of Scarpa's triangle, four inches below Poupart's ligament. 

To apply the ligature to the artery at this point of its 
course, the leg should be flexed upon the thigh, and the 
thigh abducted and rotated outward, the position of the 
internal saphenous vein ascertained by pressure applied 
above, and an incision three inches in length made along the 
inner border of the sartorius muscle, dividing the skin. The 
superficial and deep fasciae are now divided on the director, 
and the border of the sartorius muscle sought. This muscle 

can be distinguished 
by the direction its 
fibres take obliquely 
downward and in- 
ward. Drawing the 
muscle outward, the 
sheath of the vessels 
is exposed, and 
should be opened to 
a slight extent. The 
ligature needle 
should be passed 
carefully from with- 
in outward, avoiding 
the vein (Fig. 277). 
In performing this 
operation, it should 
be remembered that 
the femoral vein lies 
at this point beneath 
Great care is to be exer- 
cised, therefore, in passing the ligature needle, in order that 




1. The deep fascia. 

2. The sartorius muscle drawn aside. 

3. The femoral artery. 

4. The femoral vein. 

the arterv, and in close contact. 



TIIK POPLITEAL ARTERY. 551 

the vein should not be injured, and that it be not included 
in the ligature. 

Operation The superficial femoral artery in Hunter's 

canal. 

The limb being flexed and rotated outward, an incision 
from three to four inches in length, dividing the skin, is 
made in the course of the artery, over the point of junction 
of the middle and lower third of the thigh. The superficial 
and deep fascia? are to be divided on the director, and the 
outer border of the sartorius muscle sought for. This 
muscle is drawn inward, exposing Hunter's canal, in which 
are placed the artery, vein, and the long saphenous nerve. 
The canal should be opened carefully on the director, and 
nicking the sheath slightly, the ligature needle should be 
passed from without inward, avoiding the vein and long 
saphenous nerve. 

Attention is directed to the position of the artery, vein, 
and long saphenous nerve as they lie in Hunter's canal. 
At this point the vein is to the outside ; the nerve, w^hile 
it is in the canal, and before it reaches the opening in the 
adductor magnus, quits the outside of the artery and passes 
across to the inner side of the thigh. A r.umber of branches 
of the nerve are distributed to the vastus internus muscle, 
and may be mistaken for the internal saphenous. They may 
be distinguished by examining carefully their relations to 
the artery, being placed more externally than the saphenous 
nerve. The vastus internus muscle can be recognized by 
the direction of its fibres, which pass from above downward 
and outward. 

The Popliteal Artery, — Surgical Anatomy The 

popliteal artery, the continuation of the femoral, begins at 



552 



LIGATURE OF ARTERIES. 



the opening in the adductor magnus mnscle, and, passing 
obliquely downward and outward, terminates at the lower 
border of the popliteus muscle, in the anterior and posterior 
tibial arteries (Fig. '278). In its course, it lies in close 
contact with the posterior ligament of the knee-joint, occu- 
pying a lozenge-shaped space, called the popliteal space, 

which is placed between the 
lower third of the thigh and the 
upper fifth of the leg. The pop- 
liteal space is bounded above the 
knee-joint, externally, by the bi- 
ceps muscle, and below the joint 
by the plantaris and external 
head of the gastrocnemius mus- 
cles ; above tlie joint, internally, 
by the semimembranosus, semi- 
tendinosus, gracilis, and sartorius 



1 External saphenous veia. 

2. Popliteal nerve. 

3. Peroneal nerv^e. 

4. External saphenous nerve. 

5. Branch of the peroneal nerve. 

6. 6. Deep fascia. 

7. Semimembranosus muscle. 

8. Biceps muscle. 

9. 9. Cutaneous vessels and nerves. 

10. Interual saphenous vein. 

11. Popliteal artery. 

12. Popliteal vein. 




Surgical Anatomy- 
Artery. 



-Popliteal 



muscles ; below the joint, internally, by the inner head of 
the gastrocnemius muscle. The floor is formed, from above 
downward, by the lower part of the posterior surface of the 
shaft of the femur, the posterior ligament of the knee-joint. 



THE POPLITKAL ARTERY. 553 

the superior extremity of the tibia, and the fascia covering 
the popliteus muscle. The fascia lata (deep fascia) covers 
in the space, forming a firm protective membrane to the 
structures contained in it. The important bloodvessels and 
nerves are placed in the following order, from without in- 
ward : The internal popliteal nerve, the larger of the two 
terminal branches of the great sciatic is most superficial, 
being separated from the vessels which lie beneath by a 
thick layer of fat. In the upper part of the space it occu- 
pies a position to the outside of the artery, crossing it 
at the middle and passing to the inside as it leaves the 
space. 

The popliteal vein, formed by the union of the venae com- 
ites of the anterior and posterior tibial arteries, lies beneath 
the nerve. Occasionally the union does not take place below, 
and the artery is then embraced by the two veins which 
are in close contact with it. In the lower part of the space 
it is placed on the inner side of the artery, in the middle it 
is superficial to it, and crosses it to take a position on its 
outer side. 

Beneath the nerve and the vein, the artery is placed in 
close contact with the posterior ligament of the joint. 
Numerous branches are given off from the artery and nerve 
to the joint and surrounding muscular structures, and the 
vein receives the external or short saphenous and branches 
from the joint and muscles. 

The application of a ligature to the popliteal artery, owing 
to the relations it has to the surrounding structures, as well 
as the numerous branches arising from it at right angles, is, 
necessarily, an operation in which the greatest care should 
be exercised. Ligature may be performed in the upper or 
47 



554 LIGATURE OF ARTERIES. 

lower part of its course. The middle portion should not be 
interfered with, owing to its deep position, its proximity to 
the knee-joint, and its close relations with the vein and 
nerve. 

Course. — >From the opening in the adductor magnus mus- 
cle, obliquely downward and outward to the lower border of 
the popliteus muscle, traversing the middle of the popliteal 
space. 

Surface markings. — Borders of the muscles which form 
the boundaries of the popliteal space. 

General relations. — -In fro7it.-^ Above, the inner side of 
the femur; in the middle, the posterior ligament of the joint ; 
and, below, the popliteal fascia. 

Behi?id.^—The popliteal vein, layer of fat, internal pop- 
liteal nerve, fascia lata (deep fascia), superficial fascia, and 
skin. 

Inside. — Semimembranosus and inner head of the gastro- 
cnemius muscles. 

Outside. — -Biceps and outer head of the gastrocnemius 
muscles. 

Guides -Above, the border of the semimembranosus 

muscle ; below, the heads of the gastrocnemius muscle. 

Structures to be avoided External saphenous vein, 

popliteal vein, and internal popliteal nerve, with their 
branches. 

Operation. — In upper third. — -The patient being placed 
in the prone position, with the limb extended, an incision 
three inches in length should be made along the posterior 
margin of the semimembranosus muscle, dividing the skin. 
The superficial and deep fascias are next divided carefully 
on the director, bringing into view the border of the semi- 



THE POPLITEAL ARTERY. 



Fig. 279. 



membranosus muscle, which sliould be drawn inward, 
ing the internal popliteal nerve lying to the outside. 
rating carefully the layer of fat, which is usually 
between the nerve and the vein 
and artery, the latter is sought for 
beneath tlie vein, and somewhat 
to its inner side. Detaching cau- 
tiously the artery from the vein, 
the ligature needle is passed from 
without inward (Fig. 279). 

In the lower thirds between the 
heads of the gastrocnemius mus- 
cle An incision, three inches in 

length, should be made in the 
middle line, or slightly to the out- 
side of this line beginning opposite 



1. The popliteal artery. 

2. The skin. 

3. The superficial fascia. 

4. The fascia lata (deep fascia). 

5. The internal popliteal nerve. 

6. The biceps muscle. 

7. The popliteal vein. 



expos- 
Se pa- 
found 




the bend of the knee-joint, dividing the skin. The super- 
ficial and deep fasciae should be divided on the director, care 
being taken to avoid the external or short saphenous vein, 
which perforates the deep fascia in the lower part of the 
popliteal space to join the ven^e comites. Superficial 
branches of the internal popliteal nerve are also to be avoided 
in dividing the fasciae. After the division of the deep fascia, 
the nerve, vein, and artery are found, placed in the order 



556 



LIGATURE OF ARTERIES. 



Fio^. 280. 




The Anterior Tibial Artery. 



named from without 
inward, between the 
heads of the gastro- 
enemus muscle. 
Flexing the leg, so 
as to relax the heads 
of the gastrocnemius, 
the nerve and vein 
are cautiously sepa- 
rated from the artery, 
and the ligature nee- 
dle is passed from 
without inward. 

The Anterior 
Tibial Artery — 
Surgical Anat- 
omy. — At the lower 
border of the pop- 

7. Patella. 

2 External malleolus. 

3. Deep fascia. 

4. Tibialis anticas mus- 
cle. 

5. Extensor longns digi- 
torum muscle. 

6. Peroneus longus and 
brevis • muscles cut 
across. 

7. Border of fibula. 

S. Extensor proprius pol- 

licis muscle. 
9. Flexor longus pollicis. 

10. Anterior tibial artery. 

11. 11. Veuse comites. 

12. Anterior tibial nerve. 

13. Dorsalis pedis artery. 

14. The peroneal artery. 



THE ANTERIOR TIBIAL ARTERY. 557 

liteus muscle the anterior tibial artery is given off from tlie 
popliteal, and, passing between the two heads of the tibialis 
posticus muscle and then between the tibia and fibula in the 
interspace above the upper margin of the interosseus mem- 
brane, it reaches the anterior surface of the leg, and lies 
upon the interosseous membrane (Fig. 280). In the upper 
part of its course it is connected to the interosseous mem- 
brane by delicate bands of fibrous tissue, which pass over it; 
and below, it lies upon the anterior surface of the tibia and 
the anterior ligament of the ankle-joint, passing beneath the 
anterior annular ligament. As it descends it changes its 
relations to the muscles, by reason of the direction the tibi- 
alis amicus and the extensor proprius pollicis take to their 
points of insertion, lying above, between the tibialis anticus 
and extensor longus digitorum, in the middle portion of the 
leg between the tibialis anticus and extensor proprius polli- 
cis, and in the lower part between the tendon of the extensor 
proprius pollicis and the inner tendon of the extensor longus 
digitorum. Its course may be indicated by a line drawn 
from the inner side of the head of the fibula to a point mid- 
way between the two malleoli. 

The anterior tibial nerve lies to the outer side of the ves- 
sel in its entire extent. In the middle it is in very close 
relation, getting somewhat upon its anterior surface. Yente 
comites are placed upon either side of the artery, and should 
be separated before passing the ligature. 

Course — From the lower border of the popliteus muscle, 
forward through the interspace between the tibia and fibula 
above the upper border of the interosseous membrane, and 
downward on the anterior surface of the membrane to a 
point midway between the malleoli. 

47* 



558 LIGATURE OF ARTERIES. 

Surface markings Crest of the tibia and tibialis antlcus 

muscle. 

General relations. — In front — Skin, superficial and deep 
fasciae, tibialis anticus, extensor longus digitorum, and ex- 
tensor proprius pollicis muscles, anterior tibial nerve, and 
anterior annular ligament. 

Behind. — Interosseus membrane, tibia, and anterior liga- 
ment of the ankle-joint. 

Inside. — Tibialis anticus and extensor proprius pollicis 
muscles. 

Outside. — Anterior tibial nerve, extensor longus digi- 
torum and extensor proprius pollicis muscles. 

Guides Tibialis anticus, tendons of the extensor longus 

digitorum and extensor proprius pollicis. 

Structures to he avoided. — Anterior tibial nerve and venae 
comites. 

Operation. — In the upper third. — Turning the limb in- 
ward and extending it, an incision four inches in length is 
made over the course of the artery through the skin, mid- 
way between the crest oi" the tibia and the outer border of 
the fibula. The superficial and deep fasciae are divided next 
on the director, and the septum between the tibialis anticus 
and extensor longus digitorum is sought for. This may be 
recognized as the first intermuscular space from within out- 
ward, and by a white line at the lower part of the wound. 
The different muscles should also be brought into action by 
moving the foot, which will assist in distinguishing the line 
of separation. Flexing the foot, so as to relax the muscles, 
they are separated with the handle of the knife or finger, 
and the artery brought into view as it lies on the interosse- 
ous membrane, embraced between the venae comites, with 
the anterior tibial nerve to the outside. Separating the 



THE ANTEKIOR TIBIAL ARTERY. 



559 



Fis. 281. 



veins from the artery, the ligature needle is passed from 
without inward. 

In the middle third At this point the artery is reached 

by an incision, three inches in length, over the course of 
the vessel, somewhat nearer to the crest of the tibia than 
above, dividing the skin. The fasciae are divided, and the 
artery is found on the tibia, between the tibialis anticus and 
the extensor proprius pollicis muscles, with the nerve lying 
over it. Separating the nerve 
from the artery, the ligature 
needle is passed from witiiout in- 
ward (Fig. 281). In ligaturing 
the artery at this point, care 
should be taken to avoid mak- 
ing the incision too far from the 
crest of the tibia. It is to be 
remembered that the artery at 
this point approaches the tibia. 

In the lower third An inci- 
sion three inches in length, 
dividing the skin, is made along 
the external border of the tibi- 
alis anticus muscle to the upper 

1. Extensor proprius pollicis and extensor 
longus digitorum muscles. 

2. Tibialis anticus rnuscle. 
'H. Venae comites. 
4. Artery. 




margin of the anterior angular ligament, which passes 
obliquely across tlie limb from above downward, from tiie 
external to the internal malleolus. The superficial and deep 
fasciae are divided carefully on the director, and the artery 
sought for as it lies between the tendons of the tibialis anti- 



560 



LIGATURE OF ARTERIES. 



cus and extensor proprius pollicis, with the nerve to the 
outside. If not found in this position, it may be sought for 
beneath the tendon of the extensor proprius pollicis, or 
between this tendon and that of the extensor longus dim- 
torum. The ligature needle is passed from without inward, 
the venae comites having been separated from the artery. 
At this point of its course the artery is superficial, and deep 
dissections should be avoided in seekinsf it. 



Fis. 282. 



ii'l 



The Dorsalis Pedis Artery Surgical Anatomy- 

— The dorsalis pedis artery is the continuation of the ante- 
rior tibial, beginning at the point midway between the 
malleoli, and passing down the foot, near to the tibial bor- 
der, to the first interosseous space. It is superficial in its 
entire extent, lying upon the bones 
of the tarsus, crossing the astragalus, 
scaphoid, middle cuneiform and a 
slight portion of the internal cunei- 
forms, with the internal branch of 
the anterior tibial nerve to the out- 
side. At its lower part, the inner 
tendon of the extensor brevis digi- 
torum crosses it (Fig. 282). 

Course From the bend of the 

ankle forward and downward to the 
first interosseous space. A line 

1. Anterior aanular ligament of the tarsus. 

2. Tendon of the extensor proprius pollicis 
muscle. 

3. Tendons of the extensor longus digitorum 
muscle. 

4. Extensor hvevis digitorum muscle. 

5. Dorsalis pedis artery. 
Dorsalis Pedis Artery, 6. Anterior tibial nerve. 




THE DORSALIS PEDIS ARTERY. 



5G1 



drawn from a point midway between tlie two malleoli to the 
space between the first and second metatarsal bones, indi- 
cates its course. 

Surface marking Extensor proprius poUicis muscle. 

General relations In front Skin, superficial and deep 

fasciae, inner tendon of extensor brevis digitorum muscle. 

Behind Astragalus, scaphoid, middle and internal 

cuneiform bones and their ligaments. 

Inside. — Extensor proprius pollicis muscle. 

Outside Extensor longus digitorum muscle and anterior 

tibial nerve. 

Guides Tendon of the extensor proprius pollicis muscle 

and inner tendon of the extensor brevis digitorum. 

Structures to he avoided Anterior tibial nerve and 

vena? comites. 

Operation An incision, two inches in length, not 

extending below the upper point of 
the first interosseous space, is made 
along the outer border of the ex- 
tensor proprius pollicis muscle, di- 
viding the skin. The superficial 
and deep fasciae are divided on the 
director, and the artery exposed, 
lying between the tendon of the 
extensor proprius pollicis muscle 
and the inner border of the exten- 
sor brevis muscle, with the nerve to 

1. Inner tendon of the extensor brevis digitorum 
muscle. 

2. Venae comites. 

3. Tendon of the extensor proprius pollicis 
muscle. 

4. Dorsalis pedis artery. 



Fig. 283. 




562 



LIGATURE OF ARTERIES. 



Fig. 284. 




the outside. The lig- 
ature needle is passed 
from without inward, 
avoiding the venae co- 
mites (Fig. 283). 

The Posterior 
Tibial Artery 

Surgical Anatomy. 
— The posterior tibial 
artery is the larger of 
the terminal branches 
of the popliteal ; aris- 
ing at the lower border 
of the popliteus mus- 
cle,- it passes obliquely, 
from without inward, 
down on the posterior 
surface of the leg to 
the space midway be- 

1. Patella, 

2. Internal malleolus. 

3. Internal surface of the 
tibia. 

4. Deep fascia. 

o. Soleus muscle drawn aside. 

6. Tendo Achillis. 

7. Tibialis posticus. 

8. Flexor longus digitorum 
muscle. 

9. Gastrocnemius muscle. 

10. Posterior tibial artery. 

11. Venae comites. 

12. Posterior tibial nerve. 

13. 13. Internal or long saphe- 
nous vein. 



The Posterior Tibial Artery. 



THE POSTERIOR TIBIAL ARTERY. 563 

tween the internal malleolus and the tuberosity of the os 
calcis, where it terminates as the inteinal and external 
plantar arteries (Fig. 284). A line drawn from the middle 
of the popliteal space to a point behind the internal malleo- 
lus, will represent the direction it takes. In the upper part 
of its course it lies upon the tibialis posticus muscle, beneath 
the gastrocnemius and soleus muscles, covered by the inter- 
muscular fascia, which separates it from the soleus. 

As it descends it becomes superficial, and in the lower 
third passes along the inner border of the tendo Achillis, 
a short distance from its point of origin. The posterior 
tibial nerve occupies a position to the inside, then it crosses 
the artery, and passes on the outside in the remainder of 
its course. Venas comites accompany it in its entire extent. 
As it passes round the heel, it lies between the tendons of the 
flexor longus digitorum and flexor longus pollicis, embraced 
between the vense comites, with the nerve to the outside. 

Course. — Obliquely downward and inward from the lower 
border of the popliteus muscle to a point midway between 
the internal malleolus and the point of the heel. 

Surface markings.- — Inner border of the tibia and the 
tendo Achillis. 

General relations. — -In front. — -Tibia, tibialis posticus and 
flexor longus digitorum muscles, ankle-joint. 

Behind. — Soleus and gastrocnemius muscles, deep and 
superficial fascise, skin. 

Inside. — Upper third Origin of soleus muscle; above, 

to slight extent, posterior tibial nerve. 

Outside — Lower two-thirds — Posterior tibial nerve. 

Guides. — Above. — Intermuscular fascia, which separates 
the superficial and deep layers of muscles. Below. — Tendo 
Achillis. 



5G4 



LIGATURE OF ARTERIES. 



dividing the skin. 



Fig. 285. 



Structures to he avoided Internal saphenous vein, pos- 
terior tibial nerve, and venae comites. 

Operation. — In the upper third. — Placing the limb on 
the outer side, with the leg flexed and the foot extended, 
so as to relax the muscles of tlie calf, an incision four 
inches in length is made along the inner border of the tibia. 
The superficial fascia should be divided 
on the director, care being taken 
to avoid the internal saphenous 
vein which passes up the leg in 
this region between its layers. The 
deep fascia being divided, the mar- 
gin of the gastrocnemius is exposed, 
which should be drawn aside, and 
the attachment of the soleus to the 
tibia divided on the director. 
Seeking the intermuscular septum 
which binds the artery to the 
posterior surface of the tibialis 
posticus, it should be divided cau- 
tiously, and the artery exposed. 
Increase the flexion of the leg so 
as to relax to the fullest extent 
the muscles of the calf, then sepa- 
rate the vena3 comites from the 
artery, and pass the ligature from 
without inward, avoiding the pos- 
terior tibial nerve (Fig. 285). 
The posterior tibial artery can be exposed in the upper 
portion by an incision on the posterior surface of the leg 
through tlie superficial muscles. This method is not 
advised, owing to the great amount of injury inflicted on 




1. Solens muscle. 

2. Venre comites. 

3. Arterv. 



THE POSTERIOR TIBIAL ARTERY. 565 

the structures, although drainage can be better effected 
than in the metliod of operation above described. In these 
opemtions the relations of the intermuscular septum to the 
artery should be remembered. The septum is a pearly white 
membrane which covers the artery, and which can be seen 
distinctly, and recognized by its color and the transverse 
direction of its fibres. It separates the superficial and deep 
muscles, and beneath it the artery is placed with its veins 
and the posterior tibial nerve. 

In dividing tlie attachment of the soleus muscle to the 
tibia, care should be taken to avoid severing at the same 
time the origin of the flexor longus digitorum. If this 
precaution is neglected, the substance of the muscle will be 
invaded and the artery missed. Its position should be 
remembered as being on the posterior surface of the tibialis 
posticus muscle, covered by the intermuscular septum. 

In the middle third. — The limb being in the same posi- 
tion as for the ligature in the upper third, an incision three 
inches in length midway between the inner border of the 
tibia and inner edge of the tendo Achillis should be made, 
dividing the skin. Fixing the position of the internal 
saphenous vein, the superficial and deep fascia? should be 
divided on the director, avoiding it. Seek the edge of the 
tendo Achillis, and divide the layers of fascia connected with 
it. The artery, surrounded more or less by fat, will be 
found along the inner edge of the flexor longus digitorum, 
accompanied by its veins, with the nerve to the outside. 
The ligature should be passed from without inward, avoiding 
the nerve. 

In the lower third. — An incision two inches in length is 
made along the inner border of the tibia, and three-quarters 
of an inch posterior to it, dividing the skin. The sheath of 
48 



obb 



LK^^ATUEE OF AETEEIE?. 



the artery, with its venae comites. will be found imbedded in 
fat, which is peenliar to this region. Separating the veins 
from the artery, the ligature should be passed from without 
inward, to avoid the posterior tibial nerve, which lies to the 
outside. In this operation care should be taken to avoid 
opening the sheaths of the tendons which are placed on the 

posterior surface of the tibia 
Fig. 286. (Fig. 286). 

At the anUe. — A semi- 
lunar incision two and one- 
half inches in length should 
be made midway between 
the internal malleolus and 
the heel, dividing the skin. 
The strong and dense fascia 
(the internal annular liga- 
ment) covering the vessels 
and nerves, which is now 
exposed, and which is closely 
adherent to the sheaths of 
the tendons, should be 
divided cautiously on the 
director. The sheath of 
the vessels should be opened, 
the vence comites separated from the artery, and the ligature 
passed from below upward, avoiding the posterior tibial 
nerve. 




1. Skin and fasciae. 

2. Posterior tibial nerre. 
-3. Tense comiies. 

II. Posterior libial artery. 



The Peroneal Artery — Suegical Axatomt — The 

peroneal artery arises from the posterior tibial and passes 
down the posterior suiface of the leg along the outer or 
tibular side, terminating in branches on the back and outer 



THE PERONEAL ARTERY. 567 

side of the aukle. A line drawn from the posterior part of 
the head of the fibula to the external border of the tendo 
Achillis at the malleolus will indicate its course. 

Course — From point of origin from the posterior tibial 
artery an inch below the lower border of the popliteus mus- 
cle, obliquely outward to the fibula, descending along its 
inner border to the ankle (Fig. 280, 14). 

Surface marking The fibula. 

General relations In front Tibialis posticus and flexor 

longus pollicis muscles. 

Behind. — Soleus and flexor longus pollicis muscles, fascia, 
and skin. 

Outside. — Fibula. 

Guide Flexor longus pollicis muscle. 

Structures to he avoided. — The peroneal nerve. 

Operation — An incision three inches in length, parallel 
with, but behind, the external border of the fibula, should 
be made, dividing the skin. The attachment of the soleus 
muscle to the fibula must be divided, if necessary, and the 
muscle drawn inward. The origin of the flexor longus 
pollicis is to be detached, and the artery wiU be found to 
the inner side, lying beneath a strong aponeurosis on the 
anterior surface of this muscle, which must be divided. 
The ligature should be passed so as to avoid the peroneal 
nerve. 



PART VI. 
AMPUTATIONS 



Amputations are operations which are performed for the 
purpose of removing a limb or a part of a limb from the 
body. The point of separation may be either in the con- 
tinuity of the limb, through the bone, or at the articulation, 
between two or more bones. 

Conditions demanding Amputation Amputation is, as a 

rule, required in those cases in which the condition of the 
part, whether as the result of injury or disease, is such as to 
jeopardize the life of the patient or involve a more extensive 
loss of the limb, by the adoption of a more conservative plan 
of treatment. In every case of very serious injury or disease 
involving a limb, the best judgment of the surgeon, based 
upon his knowledge and experience, should be exercised in 
arriving at a decision. It is, frequently, a very doubtful 
point to decide whether a patient will sustain better the 
attendant shock of an amputation and the subsequent demand 
upon his reparative powers, than the risks of inflammatory 
conditions and the longer drain upon his system, by an effort 
to save the limb. It is further to be considered that, in 
some instances, a limb may be saved with its functions so 
impaired and the deformity so great as to render it a useless 
and obstructive appendage. The question of the occupation 



AMPUTATIONS. 569 

of the individual as well as his status in life should enter 
somewhat into the decision. To a working man, an arti- 
ficial appliance even if of rudest construction, will be of 
more service than the natural limb preserved in a deformed 
and useless condition. 

The conditions which call for amputation include injuries 
and diseases of the soft structures, of the hones and joints, 
malformations, deformities, aneurisms, and gangrene. 

The injuries of the soft tissues which may require amputa- 
tion embrace extensive lacerations and contusions involving 
bloodvessels and nerves, the results of the application of force, 
or gunshot wounds. Tlie diseases whicli may necessitate re- 
moval of the part or limb are generally of a malignant character. 
iS on-malignant growths, when of large size, may demand am- 
putation by reason of the pressure exerted. Wlien amputa- 
tion is performed for malignant tumors, the section should 
be made some distance from the seat of the disease. 

Tiie injuries of the bones which require amputation are 
associated usually with those of serious injuries of the soft 
tissues, as compound and comminuted fractures, the result 
of railroad crushes or severe gunshot wound. Where it is 
necessary to transport a patient some distance, as in military 
campaigns, it may be, in many instances, more prudent to 
amputate the injured limb than submit the patient to the 
dangers resulting from the motion and jarring incident 
to transportation over rough roads. Extensive necrosis, 
osteomyelitis, and malignant tumors of the bone, as well as 
ulcers, malignant and specific, of the soft tissues which in- 
volve the bone secondarily, demand amputation. 

Compound dislocations are sometimes of such gravity, by 
reason of complications, as to require amputation, especially 
those of the knee-joint. In diseases of the joints, amputa- 

48* 



570 AMPUTATIONS. 

tion is not often required, excision beinjj^ usually successful 
in the removal of the diseased tissue. 

Malformations^ which are causes of disability, require in 
some cases amputation. Supernumerary fingers or toes may 
be removed without danger at an early period of life. 

Deformities^ which are at the same time sources of disability 
and which cannot be relieved by excision or section of ten- 
dons, demand amputation. 

Aileurisms sometimes require amputation, as in cases of 
secondary hemorrhage, following ligature of the vessel per- 
formed for its relief, or rupture of the aneurismal sac. 

Rapture, caused in the efforts at reducing old luxations or 
complete division of the main artery of a limb, the result of 
gunshot wound, call frequently for the removal of the limb. 

Gangrene, consequent upon injury, demands amputation, 
performed preferably after the formation of the line of de- 
marcation. 

In traumatic conditions amputation may be j;erformed 
either in the primary, intermediary, or secondary period. 

The primary stage is that included between the receipt 
of the injury and the supervention of inflammation. This 
period may be limited usually to twenty-four or thirty hours, 
varying in different cases. Amputation should be performed 
in this stage as soon as reaction is established, which con- 
dition is indicated by a re-establishment of the circulation 
and a restoration of warmth and color to the surface. This 
is the most favorable period in which amputation can be 
performed and should be the time chosen if possible by the 
sm'geon for the performance of the operation. 

The intermediary stage embraces the period between the ac- 
cession of inflammation and the establishment of suppuration. 
Amputation should be performed in this stage only when 



INSTRUMENTS. 571 

it cannot be avoided, as may happen in accidents in which 
the patient may not obtain the services of the surgeon until 
the primary stage has elapsed, and the conditions are such 
as to demand immediate interference. 

The secondary period is that in which the inflammation 
has passed to the stage of suppuration, the acute symptoms 
having measurably subsided. While this stage offers better 
prospects of success than the intermediary, it is still an un- 
favorable one, owing to the state of exhaustion which exists 
after the subsidence of the active inflammation. In this 
stage, tonics and good diet will improve the patient's condi- 
tion and place him in a more favorable state for operative 
interference. Patients are frequently permitted to pass into 
this stage on account of the opposition of the patient or of his 
friends to the performance of amputation when the primary 
stage is present. 

INSTRUMENTS USED IN AMPUTATIONS. 

The instruments and appliances required in performing 
these operations are knives, saws, bone-nippers, dissecting 
forceps, artery forceps, tenaculum, ligatures, sutures, suture- 
needles, scissors, retractors, and tourniquet. 

1. Knives. — These consist of amputating knives, large 
and small, the catlin, bistoury, and scalpel. 

The amputating knives may vary in length from seven to 
twelve inches; in width, from three-eighths to three-quarters. 
They should have thick backs, the principal cutting edge 
extending the whole length of the blade, and the edge upon 
the back not longer than an inch and a half. They should 
be mounted in strong and roughened handles (Figs. 287 
288, 289). 



572 



AMPUTATIONS. 



The catUn or douhle-edged knife (Fig. 290) is used, and 
forms part of the operating cases ; it is employed to divide 
the interosseous membranes and intervening tissues in am- 



Figs. 294. 293. 292. 291. 290. 289. 288. 287. 




INSTRUMKNTS. 



i)7:] 



putations of the forearm and leg. It can be dispensed with, 
the bistoury or scalpel accomplishing this portion of the 
operation equally well. It should not be used to make flaps 
by transfixion, as the borders are liable to be cut in a jagged 
manner by the double cutting edge of the instrument. 



r. 295. 




Fig. 297. 




The bistoury should have a narrow, sharp-pointed blade 
three inches in length, with a strong back to it (Fig. 291). 



574 



AMPUTATIONS. 



The scalpel should have a strong blade three inches in 
length, with a broad body and a sharp point (Fig. 292). 

2. Saws. — These may be of two kinds. The one for 
larger bones should be ten inches long by two and a half 
wide; strong, with heavy back, and teeth not too widely 
set (Fig. 295). For the bones of the hand, a small saw, 
called tlie metacarpal saw, is employed (Fig. 296). A small 
saw, with a movable back, is used for the foot (Fig. 294). 

3. Bo7ie-nippers or cutting pliers are used for dividing 
the bone in amputation of phalanges or cutting off rough 
edges left by the saw. The blades should be short and 
sharp, and the handles long and strong (Fig. 297). 

4. Artery Forceps are used to seize the divided vessels. 
The blades should be toothed, so as to hold firmly, and ex- 
Fig. 298. 




Fig. 299. 




panded a short distance above the point, in order that the 
ligature may slip over easily, and not include the point in 
the knot. They should fasten with a spring or c^tch (Figs. 

298, 299). 



INSTRUMENTS. 



575 



5. The Tenaculum. — A sharp, slightly curved hook (Fig. 
300). This is used to penetrate the coats of the vessel and 
hold it while the ligature is applied, or to pick up a mass of 
tissue when it is not possible to isolate the artery. 

6. Ligatures, sutures, suture needles, and scissors have 
already been described (pp. 479-486). 

Fig. 300. 




7. Retractors — These are formed from pieces of strong 
muslin, six to eight inches wide and of proper length to 
embrace the limb, one end being torn into two or three 
tails. Tliey are applied around the bone to retract the 

Fig. 301. 




Fig. 302. 




soft structures, and prevent injury to them by the saw, and 
also to protect them from tlie bone dust (Figs. 301, 302). 



576 AMPUTATIONS. 

In securing the flaps in apposition bv sutures, that first 
introduced should be in the centre, and should be carried 
in a direction so as to pass first through the most dependent 
flap. The remaining sutures should be applied on either 
side of the first, alternately, so as to support the flaps 
equably and prevent dragging. Care should be taken to 
avoid the introduction of too many sutures — a suflftcient 
number only to bring the edges in accurate apposition should 
be used. If the subcutaneous tissue protrudes between the 
edges of the flaps as they are drawn together, it should be 
turned in and the cut surfaces placed evenly in contact, 
folding in of the edges being carefully prevented. 

Adhesive strips, compress, and roller are required in the 
living subjects to complete the dressing. 

Methods of Controlling Hemorrhage In per- 
forming amputations in the living subjects, it is necessary to 
adopt means for controlling hemorrhage after section of the 
bloodvessels. For this purpose the tourniquet, an instru- 
ment devised by Morel in 1674, and subsequently modified 
by Petit, has been employed (Figs. 303, 304). Within 
a few years. Prof. Esmarch, of Germany, has introduced an 
apparatus for bloodless operations, which consists of tliree 
yards of red elastic and four feet of rubber tubing, with hook 
and chain. The elastic bandage measures two and a half 
inches in width, and is applied to the limb by spiral turns, 
beginning at the distal point and terminating a short dis- 
tance above the point where section is to be made. The 
rubber tubing, which is three-eighths of an inch in width, 
is then applied by two or more turns just above the border 
of the last turn of the bandage, and fastened securely by the 
hook and chain (Fig. 305). On removal of the bandage, 



METHODS OF CONTROLLING HE3I0RRHAGE. 577 

the limb presents a blanched appearance, and on section the 
vessels and tissues are found free from blood. In the place 

Fig. 303. 




of the red elastic, an ordinary rubber band of the same 
length and width can be employed. To avoid a possible 
injury to the nerves of the part by undue pressure on the 
part of the rubber tubing, the author suggested, and employed 
some years since, a rubber band, measuring one and a half 
inch in width, as a substitute for the tubing. It was found 
to answer the purpose of making pressure equally as well as 
the tubing, and to avoid injury to the nerve structures (Fig. 
306). 

40 



578 



AMPUTATIONS. 



Fig. 304. 



Fis. 305. 





When it is not thought needful to apply the tourniquet or 
bloodless apparatus the hemorrliage may be controlled by 



306. 




digital pressure as shown in Figs. 307, 308. In cases of 
hemorrhage following injuries or gunshot wounds an im- 



METHOD* OF CONTROLLING HEMORRHAGE. 579 

Fiff. 307. Fijr. 308. 





provised tourniquet may be employed, made as represented 



in Figs. 309, 310. 




Yis. 310. 




The instruments which are required in performing am- 



580 



AMPUTATIONS. 

Fig. 311. 




putations are arranged in a convenient manner in the 
amputating-case (Fig. 311). 



METHODS OF AMPUTATION. 



There are two principal methods of amputation ; the 
circular and the flap. The oval may be regarded as a 
variety of the circular, and the rectangular of the flap 
method. 



The Circular Method This operation may be de- 
scribed as consisting of three staores. 

The first stage includes the division of the skin and 
superficial fascia ; the second, that of the muscles and 
other structures to the bone ; and the third, section of the 
bone. 



THE CIRCULAR METHOD. 



581 



In performing the operation, tlie opei'ator stands so as to 
enable him to grasp the proximal part and retract the super- 
ficial tissues with the left hand ; then, stooping so as to place 
his face on a level with the limb, he carries the amputating 
knife, held lightly in the right hand, around to the opposite 
side of the limb until the blade is perpendicular to the floor, 
pressing the heel firmly into the tissues (Fig. 312). He 

Fijr. 312. 




then makes a circular cut around the limb, rising as he makes 
it, so as to complete the entire incision with one motion. 

Separating the skin and fascia by careful dissection 
(Fig. 313), to the extent of two or two and a half inches, 
the cuff or fold thus formed is turned back, and the knife 
is carried about the limb just below its border in the same 
manner as above described, dividing the muscles and other 
structures to the bone. A circular sweep is now made 
around the bone, dividing the periosteum, which, with the 
muscular structures, is dissected up to the extent of an inch 

49* 



682 



AMPUTATIONS. 



or more. The retractor is now applied, the tails being 
directed upward, and crossed in such manner that they, 
with the body of the retractor, completely cover the cut 
surfaces. The tissues being firmly pressed back, tlie saw, 
held vertically, is applied to the highest point exposed 



Fig. 313. 



Fig. 314. 





(Fig. 314), and drawn from heel to point, steadied carefully 
by the thumb-nail of the left hand, and the bone divided 
by short, light, and even strokes. If two bones are to be 
sawn, the saw should be used so that the smaller and most 
movable shall be divided first. 

The vessels are now to be ligatured, spicula of bone (if 
any exist) removed by the bone nippers, the projecting ends 
of nerves and tendons retrenched, and the edges of the fold 
of skin brought into apposition transversely, and fastened 
together by means of sutures. 



THE CIRCULAR METHOD. 



583 



In applying ligatures to the arteries after amputation, the 
divided end is to be seized with the artery forceps (Fig. 



Fiff. 31 




315) or transfixed by the tenaculum, and drawn out (Fig. 

316) from the tissues so as to isolate it — any structures 



Fig. 316. 




which adhere to the artery can be pushed back by the 
handle of the knife, or carefully removed by dissection. 



584 AMPUTATIONS. 

Great care should be taken to avoid the inclusion of the 
nerve in the ligature, else the most serious consequences 
may ensue, such as secondary hemorrhage or tetanus. It 
is important that the end should be cut across straight, and 
not obliquely, and that the ligature should be applied a 
sufficient distance from the divided end to insure complete 
occlusion of the vessel. One end of the ligature should be 
cut off close, and the other brought out between the flaps at 
the nearest point to the surface. The most important vessel 
may be indicated by a knot tied in the ligature, or the two 
ends may be allowed to remain, and be then knotted. 

It is important that the ligature should be applied securely 
to the artery, and to accomplish this the reef-knot should 
always be used. To tie this knot successfully the following 

Fi^. 317. 




method is given by Mr. Heath. The ligature is to be held 
in the palm of the right hand between the thumb and index 
finger, the end is then to be thrown around the forceps 
closely and caught with the left hand ; the right hand is 
now brought under the end in the left, when that end is to 



THE CIRCULAR MKTIIOD. 



58o 



be crossed over the right thumb and inserted between tlie 
third and fourtli fingers of the right hand (Fig. 317), the 

Fig. 318. 




left hand at the same moment seizes the outer end, and thus 
an interchange is effected, and the ends of tlie threads are 
drawn out (Fig. 318). The index fingers or thumbs can be 



586 



AMPUTATIONS. 



Fig. 320. 




used to draw this knot tight (Fig. 319). The knot is com- 
pleted by another tie, the same manoeuvre being effected, 
taking care to begin with the opposite hand to that which 
began before. 

Where the cut end of the artery is short and deeply im- 
bedded in the tissues the 
ligature may be applied by 
transfixing the tissues with 
a handled needle, armed 
with a ligature which is 
deposited as is shown in 
Fig. 320. The double liga- 
ture should be cut and each 
half tied and tiien a turn 
should be made around the 
entire vessel. The method 
of applying haemostatic for- 
ceps after amputation is 
shown in Fig. 321. He- 
morrhage may be controlled 
in some instances by torsion 
(Fig. 322), or by the in- 
troduction of acupressure 
pins, of which different me- 
thods are employed (Fig. 
323). 

As the ligatures are lia- 
ble to become adherent to 
the dressings, it is a good 
plan to fasten them to the 
surface by short pieces of 
adhesive plaster, so as to 



THE CIRCULAR METHOD. 
Fig. 321. 



587 




prevent them from being pulled upon when the dressings are 
removed. 

The projecting ends of the nerves should be removed, in 
order to prevent them from being held between the flaps, 



588 



AMPUTATIONS. 

Fig. 322. 




and thus, after union has occurred, liable to be submitted to 
pressure. The tendons should be cut off close, as their pre- 
sence interferes with the healing process. 

Ficr. 323. 




Several points are to be noted by the surgeon In perform- 
ing the circular operation. When the circular cut around 
the limb is made, care should be taken that the point of the 
knife does not strike the face as it turns. It happens some- 



THE CIRCULAR METHOD. 589 

times that tlie incisions are not made successfully because 
tlie knife is drawn around the part, the heel alone being kept 
in contact with the surface. The knife should be drawn 
gradually from heel to point as it passes around the limb, 
finishing the cut with the point. The amount of pressure 
to be employed varies somewhat with the condition of the 
part and of the knife, whether sharp or dull. Practice 
alone will enable the operator to acquire proper knowledge 
upon this point. 

Before making the second incision, it is directed that the 
cuff of skin and fascia, which has been formed, should be 
turned up. In some cases, owing to the conical shape of 
the limb, this may be difficult to accomplish. When it is 
found difficult to turn this back, it should be slit open at one 
side. 

In making the second incision, the assistant should hold 
back the cuff, so as to avoid its section as the knife is car- 
ried around the limb. 

The periosteum is directed to be dissected up to some 
distance ; this is desirable, in order to secure good repair 
in the divided end of the bone and prevent exfoliation. 

In sawing the bone the saw should be held vertically, so 
as to divide it from side to side, and thus avoid a liability 
to fracture or splintering. Proper care should always be 
taken in supporting the portion to be removed during this 
part of the operation. 

The manner in which the limb is held and supported is 
of great importance, as splintering and fracture occur fre- 
quently from want of proper knowledge upon this point. 
The limb should be covered with a towel or bandage, so 
that a firm grasp can be taken ; and, while it is firmly sup- 
ported, without being raised up or down, it should be drawn 
50 



590 



AMPUTATIONS. 



away with moderate force from the body in the line of its 
long axis. This action will cause a separation of the ends, 
and prevent binding of the saw, while steady support com- 
bined with it, will remove the weight of the limb. 

The circular method of amputation can be employed at 
any part of the limb ; it is preferably used where there are 
two bones or an absence of muscular structures, as in the 
lower portions of the forearm and leg. 

The Modified Circular Method This name is 

given to an operation which consists in forming two short 

Fig. 324. 




flaps of skin and superficial fascia by cutting from without 
inward, and dividing the muscles by a circular incision (Fig. 



THE FLAP METHOD. 591 

324). It may be employed in cases where tliere is a 
redundancy of muscular tissues. 

The Flap-Method Amputation by the flap method 

consists in the division of the tissues so as to form one or 
more flaps, with which the end of the bone is covered. 
Tliese flaps may be made by cutting from without inward 
to the bone, or from ivithin outivard, the knife transfixing 
the tissues, and cutting from the bone to the surface. In 
some instances, one flap is made in the first way, and the 
other in the second. The flaps may vary in number from 
one to two or more, according to the circumstances of each 
case. The length also varies according to the size of the 
limb. A safe rule to adopt is to make them equal in length 
to three-quarters the diameter of the limb at the point of 
section of the bone. Tliey may be made antero-posteriorly, 
laterally, or obliquely, and may include all of the structures 
to tlie bone, or may be made of skin and fascia alone, the 
muscles and other structures being divided circularly. They 
may be cut of equal lengtli, or one may be longer than the 
otlier, according to the amount of muscular tissue in the 
part involved. They are, as a rule, convex in shape, 
terminating in a point more or less oblique. Care should 
be taken to avoid making them too oblique ; and it should 
be remembered that it is always better to have an abundance 
of tissue rather than too small an amount. In the one case 
the redundant tissue can be retrenched ; in the other it may 
be found difficult to supply the deficiency. If, in any case, 
the flaps are found to be too short, and there is danger of 
protrusion of the bone, the bone should then be sawn througli 
at a higher point. 

In performing the operation by transfixion the operator 
stands so as to grasp the proximal part of the limb firmly 



592 



AMPUTATIONS. 



with the left hand. Raising the tissues so as to see that 
the flaps to be made will be, as nearly as possible, of equal 
size, the point of the amputating knife is entered on the 
side, midway between the upper and lower borders of the 
limb, and pushed inward until it strikes the middle of the 
bone. The handle of the knife is then depressed until the 
point is carried over the bone, and then elevated, returning 
the blade to the horizontal position, in order to bring the 
point out exactly opposite to the point of entrance. The 
knife, still in the horizontal position, and in close contact 
with the bone, is carried downward with a sawing motion 
to a sufficient distance, and then turning its edge to about 
an angle of 45°, it is carried upward and outward until the 
tissues are divided. In cutting outward, the handle of the 
knife should be gradually turned in the hand, so that when 
the edge leaves the tissues it will look directly upward. In 

this way, a pointed flap 



Fig. 325. 




will be avoided. Turn- 
ing back the flap, the 
knife is re-entered at the 
same point as before, car- 
ried under the bone by 
movements similar to 
those used in making 
the first flap, the 
point brought out as 
before (Fig. 325), and the 
flap cut in the same way 
as the first. The flaps 
are now held back by 
the retractor, and the 
remainins tissues and 



TlIK FLAT AIKTIIOD. 593 

periosteum divided by a circular cut of the knife. The 
periosteum is dissected back to a sufficient extent, and the 
bone sawn. Tiie arteries are ligatured, nerves and tendons 
retrenched, and sutures introduced, as described in the cir- 
cular method. 

In transfixing the tissues in this operation in the arm 
and thigh, it is important that the principal artery should 
not be pierced by the point of the knife in making the first 
flap, as a punctured wound or a longitudinal slit will be 
made in the vessel which may cause serious trouble, the 
operator being compelled to dissect back to a sound portion 
of the artery in order to apply the ligature. If the position 
of the main artery is well ascertained before the incisions 
are commenced, the point of the knife can be passed so as 
to avoid it. An effort should always be made to leave it in 
the flap which is made last thus deferring its division to the 
later stages of the operation. 

In the arm and thigh, where the superficial fascia is usu- 
ally abundant and the skin is very elastic and moves readily 
over the subjacent muscular tissues, care must be taken, in 
cutting from within outward, to retract the skin firmly, so 
that when the section is completed the muscles and skin will 
be divided on the same line. If this important injunction 
is unheeded, the operator will find a projecting mass of mus- 
cular tissues without sufficient skin to cover them. This 
mass should be retrenched, otherwise, if an attempt is made 
to pull the skin forcibly over it and then apply sutures, 
these will cut through, owing to the undue tension. It may 
be advisable, in some instances, when cutting from within 
outward, to turn the knife so as to divide the muscles at a 
higher point than the skin, thus reducing the muscular mass 
in the flap and giving a longer skin flap. 

50* 



594 AMPUTATIONS. 

In forming antero-posterior flaps by transfixion, tlie 
anterior flap should be made first. In the lateral flap 
operation, the outer flap should be cut first. As a rule, 
the principal artery should be contained in the flap formed 
last. 

An effort should be made, in cutting the flaps in the living 
subject, to form them with regard to shape and size, so as 
to obtain a stump to which an artificial appliance can be 
adapted with comfort to the individual, the line of the cica- 
trix being so placed as to be free from pressure. 

In the flap method, the flaps may also be made by cutting 
from without inward. When this plan of forming them is 
adopted, the amputating knife or, if preferred, a large scalpel, 
should be entered on one side, at the point fixed upon for 
section of the bone, and carried over the front of the limb, 
making a curvilinear incision downward to the extent nec- 
essary to give proper length to the flap, bringing it out at a 
point just opposite to that of entrance. With this incision, 
the skin and superficial fascia, or the entire structures to the 
bone, are divided. The posterfor flap may be formed in the 
same way, or by translixion. 

The Oval Method (Scoutetten's method) This 

method, as stated above, may be regarded as a modification 
of tlie circular. It may be employed when amputation is 
performed in the continuity of a limb, but it is more fre- 
quently adopted in disarticulations or amputations through 
the joints. The incision is made by introducing the knife a 
few lines above the point of section of the bone or above the 
joint, carrying it downward in a vertical line for a short 
distance, and then sweeping it about the limb in an oblique 
direction, dividing all the structures to the bone, and re- 



THE llECTANGULAR FLAP METHOD. 



595 



turning to the point of entrance. It may also be made by 
two incisions in the sliape of the letter v reversed, these 
being made first and tlien united by a transverse cut. 

The Rectangular Flap Method (Teale's method). — 
Tins is a moditication of the double flap, and consists in 
forming two rectangular flaps, a long and a short one. The 
length and breadth of the long flap should be equal to one- 



Fiff. 326. 



Fig. 327. 



Fiff. 328. 




Aa//" (preferably one-third) the circumference of the limb at 
the point of section of the bone, and the short flap, which 
should contain the vessels, should measure one-eighth the cir- 
cumference, or one-fourth the length of the long flap. The 



596 AMPUTATIONS. 

lines of incision should be traced out upon the part (Fig. 
326), and in cutting the flaps tlie knife should be carried to 
the bone, including all of the structures. The flaps should 
be dissected up, and the bone divided as in the otlier 
methods, care being taken to remove all rough points and 
spicula (Fig. 327). The long flap is then drawn over the 
end of the bone, and attached by sutures to the short one at 
the end and sides. Tlie apposed edges of the long flap 
sliould also be secured by sutures (Fig. 328). 

The different methods of amputation described above may 
be employed witli advantage in different parts of the limb. 
When thus employed they are found to serve well the pur- 
pose of a covering to the divided bone. Certain objections 
have been urged against the circular and flap methods to 
which reference may be made. The time required in the 
circular method to fashion the flap is objected to, and is of 
little consequence so long as the patient is under the influ- 
ence of an anaesthetic. The separation of the flap from the 
deep fascia causes the division of a number of nutrient 
vessels, and leaves it dependent entirely upon those at tlie 
point of reflection, which may not be sufficient to supply 
nutrition in long flaps and in those in which mucli contusion 
of the parts has occurred. It is desirable in order to facilitate 
tlie turning over of the flap and to prevent too much tension 
at the time to incise it. The advantages of this method are 
the absence of danger of bone protrusion, of the formation of 
a conical stump, of the occurrence of secondary hemorrhage, 
by reason of the straight incision of the arteries, and of deep- 
seated suppuration. 

The principal objections to the flap method are the oblique 
incision of the arteries, the occurrence of neuralgia on 
account of the pressure exerted, and the delay in union 



THE AFTER-TREATMENT. 597 

owing to the large cut surfaces. The large muscular cushion 
left after the flap operation, and which is claimed as an 
advantage, gradually undergoes atrophy, leaving in its place 
a mass of connective tissue. 

The great objections to the rectangular flap is the large 
surface divided and the amount of bone removed. The 
special methods of operation upon the foot and at the various 
articulations are modifications of the principal varieties 
ada[)ted in each case to the configuration of the part. 

After treatment. — Hemorrhage having been controlled 
and the flaps adjusted by sutures, and, if necessary, supported 
by adhesive strips, the dressings should be applied. Much 
stress was laid formerly on the importance of allowing the 
wound to remain unclosed or pai'tially closed until all appre- 
hension of heraori-hage had passed away and the surface had 
become glazed with a layer of lymph. The edges were then 
approximated and the stump was dressed with the dry or wet 
dressings. 

The introduction of the antiseptic methods of wound 
treatment has effected a change, in the opinion of surgeons, 
with regard to the necessity of delay in applying the perma- 
nent dressings after amputation and in the character of dress- 
ings employed. The use of antiseptic agents at the time of 
the operation, the thorough drainage of the wound by the 
introduction of drainage tubes, whereby the wound fluids are 
immediately removed and disinfected in the dressings, with 
the accurate apposition of the cut surfaces by the employment 
of the various forms of sutures of coaptation, approximation, 
and relaxation, remove to a great extent the causes which 
give rise to unfavorable conditions during the progress of the 
after-treatment. While it is important that all oozing of blood 
should cease and that all clots should be carefully removed 



598 A:\iprTATioxs. 

before closure of the wound, it is known that under the anti- 
septic methods the small quantity of blood not removed by 
the drainage tubes may undergo a process by which it 
becomes a pabulum for the cells of tiie newly organized 
tissue. The occurrence of these favorable conditions under 
antiseptic methods should not, however, relax the vigilance 
of the surgeon in all efforts to obtain complete control of the 
hemorrhage following operation by the careful application ot 
ligatures or other means before closure of the wound. 

TVhen the antiseptic dressings are employed the vessels 
sliould be ligatured by carbolized animal or silk ligatures, 
the former of which should be cut close and the latter cut 
in the same manner or brought out between the flaps at 
the nearest points. The surfaces of the flaps should be 
thoroughly douched with the carbolized or sublimated solu- 
tion, a drainage tube should be introduced at the bottom 
of the wound between the flaps, one end being brought out 
at each angle and secured by a loop of silk ligature cut 
off close. The flaps should now be approximated and held 
in contact by an assistant, while the metallic sutures are 
introduced. Carbolated or sublimated solutions should 
now be thrown through the drainage tube to douche the 
interior of the wound. If deemed necessary, strips of adhe- 
sive plaster may be employed to afford support to the flaps, 
and the carbolated or sublimated 
^^-- ■^^^* dressings applied as directed in 

tlie cha})ter on Surgical Dress- 
ings. Over the dressing a band- 
age should be applied, beginning 
above and passing down to the 
end of the stump, which should be 
covered by recurrent and circular turns. Tiie stump should 
be placed upon an inclined plane tbrnied of pillows, and pro- 




THE AFTEII-TRKAT.MKNT. 509 

tectcd from pressure of tlie bedclothes by a frame (Fig. 
329). Redressing should not be made before the expira- 
tion of four to six days, the temperature record being the 
guide for the surgeon in this respect. If the temperature 
remains uniform or with slight variation the dressings should 
not be disturbed until the fifth to the sixth day, at which 
period the process of repair is well advanced. After this 
the dressings should be renewed in accordance with the 
amount of suppuration, if that has occurred, or the necessity 
for the removal of sutures or ligatures. Both should be 
gradually removed, the former when they have ceased to 
afford support to the edges or are cutting through the tissues, 
and the latter from time to time as they show on slight 
traction a disposition to separate. The ligature upon the 
main artery should be allowed to remain for a longer period 
than the smaller branches, and traction should be made 
very cautiously lest it be detached prematurely and fat^l 
hemorrhage occur. 

Treatment by '• pneumatic aspiration" or by the " open 
method" may be employed if deemed advisable. The former 
mode of treatment, devised by Maisonneuve, is designed to 
exclude the air from the stump, the flaps of which are held 
together simply by adhesive strips, and consists '• in surround- 
ing the stump with a closely-fitting hood of vulcanized 
rubber, to the centre of the free extremity of which is 
attached a tube of similar material, from two to three feet 
in length, the opposite end of which is fitted, by means of a 
metallic canula, in a rubber plug secured in a gallon glass jar. 
A second metallic tube pierces the rubber plug, and is con- 
nected with a vulcanized tube of convenient length attached 
to a brass exhausting pump. A few strokes of the piston, 
morning and evening, suffice to draw the discharges from 



GOO AMPUTATIONS. 

the Stump into the jar, where, in the absence of air, they 
accumulate without the danger of decomposition." 

The '* open method" of dressing dispenses with sutures, 
adhesive strips, and bandages during the first week of treat- 
ment. It is necessary that the flaps, in the amputations 
treated by this plan, should be entirely cutaneous, and, on 
account of the great shrinkage which occurs, proportionally 
large. In the method, as practised by the late Dr. James 
Wood, of ]Sew York, ''the wound is douched immediately 
after the operation with a moderately strong solution of 
carbolic acid and then filled with balsam of Peru, the drain- 
age being accomplished by the interposition of a pledget of 
oakum soaked in the balsam. If the stump becomes hot or 
painful from overaction the dressing is removed, otherwise 
it is allowed to remain undisturbed for twenty-four hours. 
After this the wound is douched twice daily with a weak 
solution of carbolic acid, and the balsam and oakum applied 
as in the first instance. At the end of the sixth or eighth 
day, w^hen suppuration has nearly ceased, the flaps are 
moulded into shape and gradually approximated with adhe- 
sive strips." This method of treatment, as stated by the late 
Prof. Gross, is not liable to be followed, as the ordinary 
close dressing, by erysipelas, abscesses, pyaemia, septicaemia, 
or suppurative fever. 

Affections of the Stump These may be primary or 

secondary, and local or local and constitutional in their 
origin. 

The primary conditions include hemorrhage, muscular 
spasm, pain, inflammation of a high grade, osteomyelitis, and 
protrusion of the bone due to the retraction of the muscles. 

Primary hemorrhage may occur from a few hours after 
the dressing to the fourth or fifth day. 



AFFECTIONS OF THE STUMT. GOl 

Hemorrliage of slight character is liable to follow in every 
case of amputation and to stain the dressings more or less. 
This form of hemorrhage does not require any special atten- 
tion. "When, however, the dressings are soaked with blood 
of a red or dark color they should be immediately removed 
and attention should be given to the source of the bleeding. 
Primary hemorrhage may occur from an artery which did 
not bleed at the time of the dressings and to whicli a liga- 
ture was not applied ; from an artery cut obliquely and, as a 
result, imperfectly ligatured ; from a vessel in a state of dis- 
ease or from one imbedded in inflamed tissues ; and it may also 
take place from the vessels of the Haversian canals. Etforts 
should be made to arrest the hemorrhage by elevation of the 
stump, the application of cold and digital compression of the 
main artery, combined with compression of the stump by a 
firmly applied bandage. If these measures do not succeed 
the flaps should be separated to sufficient extent to secure the 
bleeding vessel with a ligature. Hemorrhage from the 
divided bone may be arrested by pressure made with a com- 
press of lint to which a thread is tied, applied directly to 
the part, or the bleeding points may be plugged with pieces 
of catgut ligature, beeswax, or a plug of soft wood, sufficiently 
long to project beyond the edges of the flaps, and which may 
be withdrawn in a few days. The application of caustics 
should not be made lest necrosis be induced. 

Spasms of the muscles are very liable to occur after ampu- 
tation especially in nervous subjects and should be allayed 
by the hypodermic injection of morphia. The spasms are 
frequently accompanied by excessive pain, which should be 
relieved promptly by morphia. 

Erysipelatous inflammation, a frequent complication of am- 
putations under the old form of dressings employed, is not 
51 



602 AMPUTATIONS. 

liable to occur under antiseptic methods. In case of its 
occurrence it should be treated by constitutional and local 
remedies. If excessive suppuration occurs the pus should 
be conducted from the wound by drainage-tubes and fre- 
quent douching of warm antiseptic lotions should be made. 

Gangrene^ liable to occur in debilitated subjects and in 
badly ventilated and crowded hospitals, should be treated by 
the internal administration of stimulants and tonics and by 
the local application of counter-irritants in the earlier stages, 
and with poultices in the later stages to facilitate the removal 
of the slouorhs. Thorough drainao;e of the wound should be 
maintained, and antiseptic solutions should be freely em- 
ployed. 

Osteomyelitis may result from injury to the bone at the 
time of the accident or when the bone is divided by the saw 
in the amputation. It sometimes accompanies erysipelas 
and pyaemia, and is a very grave complication. It should 
be treated by the free use of antiseptic solutions thrown into 
the wound, and complete drainage to remove the wound 
secretions. Constitutional agents should be also employed to 
maintain the strength of the patient. When death of the 
bone occurs its removal should be delayed until the condition 
of the patient is sufficiently improved to enable him to with- 
stand the shock of the operation. 

Protrusion of the hone occurs as the result of inordinate 
retraction of the muscles, especially after amputations of the 
thigh, where the powerful muscles of the region are divided. 
The application of a firm bandage beginning above and 
passing downward to the end of the stump will frequently 
prevent retraction of the muscles. Extension by means of 
Aveights and pulley may also be employed as in fracture of 
the thigh. Subcutaneous section of the muscles may also 



AFFECTIONS OF THE STUMP. G03 

be practised if other means fail. Section of the bone at a 
higher point may be performed after dissection of the tissues, 
or re-amputation may be required to provide a satisfactory 
stump. 

The principal secondary affections of the stump are 
secondary hemorrhage, necrosis of tlie bone, and neuralgia. 

Secondary hemorrhage may occur from the eighth day to 
the second or third week, and may be the result of premature 
separation of the ligature due to organic disease of tlie 
arterial walls or of sloughing caused by gangrene. It may be 
arrested by digital compression of the main artery of the 
limb, or by the introduction of an acupressure needle. If 
these measures are not successful, ligature of the main 
artery should be performed some distance above the stump. 
Hemoi-rhage sometimes occurs in connection with necrosis of 
the bone, and is arrested upon removal of the sequestrum. 

Necrosis of the bone may occur from injury inflicted at 
the time of the accident or operation, as the result of exces- 
sive inflammation and suppuration, or of interference with 
the proper blood supply causing defective nutrition. No 
efforts should be made to remove the sequestrum until it is 
completely detached, at which period it may be accomplished 
by careful dissection of the soft tissues. Violence should 
be avoided in extracting the sequestrum lest serious hemor- 
rhage be provoked. 

Neuralgia, due to peripheral or central conditions, occurs 
as an affection of the stump in persons of a nervous organi- 
zation, and more frequently in women than in men. The 
peripheral form may be the result of the pressure exerted 
upon the nerves of the stump by the cicatrix in the flap 
or by a bulbous enlargement of the ends of the divided 
nerves. Ordinarily the nerve ends undergo enlargement, 



G04 AMPUTATIONS, 

and give rise to no unplea??ant condition. When they assume 
the proportions of a wahiut, or even larger, forming a neuro- 
matous tumor, as sometimes happens, they become exqui- 
sitely painful. Internal medication is usually of little avail, 
especially in the severer forms, nothing short of excision or, 
if they are multiple, amputation, affording permanent relief. 
In addition to the secondary affections above mentioned, 
there are a number of sufficient importance to claim atten- 
tion, as caries of the bone ; choreaic spasms of the muscles 
of the stump ; the formation of a bursa upon the end of the 
stump caused by the pressure of an improperly constructed 
and adapted artificial limb ; a conical formation of the stump 
due to insufficient flap, retraction or sloughing of the flaps; 
fibroid, fatty, or malignant degeneration of the tissues of the 
stump caused by pressure of an artificial limb, or the recur- 
rence of malignant disease ; ulceration of the integumental 
covering of the stump, due to contracted flap or inflammation 
of the cicatrix ; eczema of the stump, the result of irritation 
in the cicatrix ; contraction of the tendons occurring chiefly 
in those of the biceps, semitendinosis and semimembranosis 
muscles of the thigh, and the tendo Achillis of the leg, the 
result usually of not maintaining proper extension during the 
after-treatment. Varicose enlargement of the arteries ot 
.the stump is a rare afl'ection, due to organic disease of the 
arterial walls. In most of the affections above enumerated, 
in the severer forms, excision or reamputation is required. 
In eczema of the stump internal remedies with local appli- 
cations are indicated, such as vaseline, with camphor and 
chloral to allay the itching, or carbolated zinc ointment. 
Subcutaneous division of the tendons should be performed 
in cases of contraction, and extension applied by weights 
and pulley. 



SYNCIIKONOUS AMPUTATIONS. 



G05 



Sf/uchi'0)WKS Amputations In railway accidents, espe- 
cially where persons are crushed beneath the wheels of" a 
train, two or more of the extremities are frequently involved 
in the injury, and require removal simultaneously. (Fig. 



Fi-. 330. 




330.) Where two of the extremities are removed it is desi"-- 
nated double synchronous amputation ; three, triple syn- 
chronous amputation. Of the former a number of operations 
have been [jerlbrmed, some of them successfully. 

51* 



606 



AMPUTATIONS. 



Fiff. 331. 



Dr. James McCann, of Pittsburg, Pennsylvania, reports, 
in a paper read before the American Surgical Association, 
and published in volume 2d of its Transactions, 29 cases of 
double synchronous amputations performed in the Western 
Pennsylvania Hospital, of which 14 recovered, showing a 
moi-tality of 51 per cent. In the same paper he records a case 

of triple synchronous 
amputation performed 
successfully by Dr. W. 
B. Low man, of Johns- 
town, Pa., upon a boy 
aged 9 years (Fig. 331 ). 
Dr. J. G. Koehler, of 
Schuylkill Haven, Pa., 
performed successfully 
a similar operation in 
1847 upon a boy aged 
13. A similar success- 
ful operation was per- 
formed by Professor 
Stone, of New Orleans. 
In 1879 Professor Jo! in 
Ashhurst performed 
successfully a double 
synchronous amputa- 
tion on a boy thirteen 
years of age. In 1882 
the author performed a 
double synchronous 
amputation upon a child 
aged eight, removing 
the left limb at the hip- 
joint, and tlie right in 




RE-AMPUTATIONS. GOT 

tlie lower tliird of tlie femur, the result of a crush by the 
wheels of a railway train. The patient died in a few hours 
after from shock. In these cases it is deemed advisable to 
remove the limbs at once and then ligature tlie vessels in 
each stump, the hemorrhage in each limb being controlled 
by competent assistants or the abdominal tourniquet. 

Re-amputations Under the heading of secondary affec- 
tions of tlie stump a number of conditions were referred to 
in which re-amputation was demanded. The operation 
should not be performed until the patient's health is such as 
to enable him to withstand the shock of the operation and 
care should be taken to guard against any undue loss of blood. 
The operation should be performed in the same manner as 
the primary amputation. In chronic diseases of the bone of 
the stump, it is sometimes difficult to determine with regard 
to the propriety of disarticulation in the place of amputa- 
tion in the continuity of the bone. The question must be 
decided in each case according to the extent of bone involved 
and the proximity to the articulation. 

Iiitra-iiterine Amputation — Instances have been recorded 
of amputation of the limbs of \.\\q foetus in utero. One, two, 
or all of the limbs may be removed, the separation being 
either partial or com[)lete. It is the generally received 
opinion that the amputation is produced by a band of false 
membrane which surrounds the limb, and by its contraction 
gradually severs the tissues. 

Constitutional effects. — Amputations are frequently fol- 
lowed by grave constitutional effects which greatly compli- 
cate the results, such as shock, surgical fever, pycBmia, and 
tetanus. These conditions should be treated upon general 
principles, the last two resulting, as a rule, fatally under 
any plan. Precautions should be taken to avoid exposure of 



608 AMPUTATIONS. 

the patient to the direct currents of cold air, wliich is liable 
to induce tetanus. The author was called to see in consul- 
tation a case, some years since, of tt tanus following amputa- 
tion at the elbow-joint. Death ensued, and an examination 
showed that the condition had been caused by ligature of the 
median nerve. 

The mortality after amputations is influenced by various 
conditions — as the age, habits, occupation, and general health 
of the patient ; the cause of the operation, whether per- 
formed for an injury or disease, the nature, extent, and situa- 
tion of the operation, the hygienic conditions which surrounds 
the patient ; tl)e proximity of the amputation to the trunk 
— whether a primary, intermediary, or secondary operation ; 
the conduct of the after-treatment — all of these conditions 
influence largely the results of amputations. The statistics 
gathered from all sources, civil, military, private, and hospi- 
tal, show that the mortality of amputations performed after 
injuries is greater than tiiose in disease. Primary opera- 
tions are, as a rule, less fatal than secondary, and amputa- 
tions of the lower show a larger mortality than those of the 
upper extremity. The moi'tality in amputations of the supe- 
rior extremity for gunshot injuries is shown by the tables of 
Prof. S. W. Gross to be 27.42 per cent., and of tlie inferior 
extremity 55.76 per cent. 

The principal points to be observed in performing ampu- 
tations may be embraced in a few general statements : — 

I. The patient or subject should be placed in the recum- 
'bent position ; the operator should take a position which 
will permit him to control his movements without restraint. 
The table should be firm and high, so as to prevent 
motion and unnecessary fatigue to the operator in bending 
over it. 



RULES TO BE OliSERVED. 609 

II. Tlie assistants sliould perform tlie duties assigned 
them with promptness ; no delay on tlieir part should attend 
the delivery of the instruments as they are required, the 
supply of sponges in proper condition, the supply and the 
proper application of the ligatures. Perfect quietude should 
be maintained, and no conversation should be indulged 
in except that which relates to the performance of the 
operation in hand. The office of tlie assistant who ad- 
ministers the anjBsthetic agent is a most responsible one ; 
his entire attention should be given to the duty assigned 
him. He should carefully watch the state of aniesthesia in 
which the patient is placed, as manifested by the circulation, 
respiration, and other symptoms. He should endeavor to 
maintain a uniform effect upon the patient of the agent used ; 
under no circumstances should he leave the patient or take 
part in any of the other duties of the operation. 

III. The proximal part should be grasped firmly, and the 
integument drawn upward so that sufficient length will be 
given to this portion of the flap. Care should always be 
taken to cut the flaps of sufficient length. Redundant tissues 
should be retrenched. Flaps cut too short require section 
of the bone at a higher point. 

lY. As a general rule, as little of the bone as possible 
should be sacriflced. In amptations for the removal of dis- 
eased structures, it is important to cut through the bone at a 
point sufficiently beyond the disease to insure healthy flaps. 
In injuries, on the contrary, all of the soft structures re- 
maining should be utilized in forming the flaps, and as much 
of the bone saved as possible. 

V. The periosteum should be dissected up to the extent 
of an inch or more, so as to assist in the reparative process 
which occurs about tlie end of the bone. 

VI. The bloodvessels requiring ligature should bo com- 



610 AMPUTATIONS. 

pletely isolated before the ligatures are applied. Great care 
should be taken to avoid the inclusion of the nerve in the 
ligature. The projecting ends of the nerves and tendons 
should always be cut off. 

VII. In approximating the edges of the flaps, the sutures 
should be introduced to such depth as is necessary to afford 
proper support. In removing the sutures, they should be 
cut with the .scissors at the side, just beyond the edge of 
the wound, and withdrawn, the borders of the wound being 
supported by the thumb and index finger of tlie free hand. 
If wire sutures are used, they should be divided in the same 
manner, or untwisted, the cut, or free, ends being bent back 
so as to straighten them, and the suture removed by gentle, 
even traction ; usually more force is required to remove the 
wire suture, and, therefore, care should be taken to support 
carefully the edges of the wound. 

SPECIAL AMPUTATIONS. 

THE LOWER EXTREMITY. 

Amputation of the Foot Surgical Anatomy — 

The foot is tiie terminal part of the lower extremity, and 
consists of three portions, the tarsus, metatarsus, and pha- 
langes (Fig. 332). 

Bones The Tarsus is composed of seven irregular bones, 

the OS caicis, astragalus, cuboid on the outside, scaphoid on 
the inside, internal, middle, and external cuneiform bones, 
placed between the cuboid and the inner border of the foot. 

The Metatarsus consists of five bones, numbered from 
within outward, and classified as long bones. 

The Phalanges are fourteen in number, two for the great 
toe and three for the remaining toes, and are enumerated 



AMPUTATION OF THE FOOT. 



on 



from the metatarsus. Tliese are also 
classified as long bones. 

Ligaments Tlie bones of the tarsus 

are attaohed to each other by strong 
doi*sal, plantar, and interosseous liga- 
ments, with intervening synovial mem- 
branes. The articulations between the 
various bones of the tarsus are of the 
diarthrodial form, embracing the ar- 
throdia and the enarthrosis. The 
metatarsal bones are united to the last 
row of tarsal bones and to each other 
by dorsal, plantar, and interosseous 
ligaments. Tiiey are connected with 
the first phalanges by an anterior 
plantar and two lateral ligaments. 

The phalanges are bound together 
by plantar and lateral ligaments. Sy- 
novial membranes line the joints. 

Muscles. — The upper or dorsal sur- 
face of the foot is covered by the ten- 
dons of the extensor muscles, which take 
origin on the anterior surface of the 
leg, and by the fleshy bellies of the ex- 
tensor brevis digitorum. 

The plantar surface or sole of the foot is well protected 
by the dense plantar fascia and the thick, fleshy masses 
formed by the flexor brevis digitorum and muscles of the 
great and little toes. The spaces between the metatarsal 
bones are occupied by dorsal and plantar interossei muscles. 

Articulations. — As amputation is performed at the various 
articulations of the foot, it is important to study the nature 




1-5. Metatarsal bones. 

6. Tibia. 

7. Fibula. 

S. Astragalus. 
9. Os calcis. 

10. Scapboid. 

11. Cuboid. 

12. Internal cuneiform. 
1.3. Middle cuneiform. 
14. External cuneiform. 
1.5-15. Pbalantres. 



012 AMPUTATIONS. 

and position of these very carefully. The articulation of 
the phalanges with each other and with the metatarsus is 
quite regular, and does not differ materially from that 
observed in the hand. Between the metatarsus and the 
second row of bones of the tarsus, the line of articulation is 
irregular, owing to the projection backward of the head of 
the second metatarsal bone, and its interlocking with the 
three cuneiform bones (Fig. 332). The mortise formed by 
the three cuneiform bones has the following measurements ; 
the internal wall is one-third of an inch deep, and has a di- 
rection obliquely backward and outward ; the external wall 
is one-sixth of an inch deep, and its direction is obliquely 
backward and inward ; the posterior wall measures about 
one-half of an inch in width, and is transverse. This posi- 
tion of the head of the second metatarsal bone should be 
particularly borne in mind in the attempts to effect disar- 
ticulation. The position of the articulation on the outside 
is indicated by a point just behind the tuberosity of the fifth 
metatarsal bone. On the inside it lies one inch in front of 
the tuberosity of the scaphoid. 

The next line of articulation is a partial one existing be- 
tw^een the heads of the three cuneiform bones and the base 
of the scaphoid, limited on the outside by the body of the 
cuboid. In disarticulation through the tarsus, this articula- 
tion is sometimes opened by mistake. The error can be 
detected at once by observing the three articulating facets 
on the base of the scaphoid. 

The line of articulation between the astragalus and sca- 
phoid and the os calcis and cuboid is, in its nature, com- 
pound, being convex anteriorly between the astragalus and 
scaphoid, and concavo-convex anteriorly between the os 
calcis and cuboid. On the outside, a point midway between 



AMPUTATION OF THE TOKS. (313 

the external malleolus and the tuberosity of the fifth meta- 
tarsal bone, indicates the position of the articulation, while 
a point just back of the tuberosity of the scaphoid fixes the 
position on the inside. 

Bloodvessels — Tlie arteries which supply the foot are the 
dorsalis pedis, on the dorsal surface, and the plantar arteries 
on the plantar surface, with their venre comites. On a level 
nearly with the line of articulation, between the tarsus and 
metatarsus, the arteries form arches across the surfaces of 
the foot, from which are given off branches which terminate 
in two digital branches on each surface of the toes. 

Nerves. — The nervous supply to the foot is derived from 
the anterior tibial and musculo-cutaneous on the dorsal sur- 
face, and the plantar nerves on the sole of the foot. Digital 
branches are given off, which follow the course of the 
arteries. 

Amputation of the Toes. — MetJiods At the phalan- 
geal articulations, or in the continuity of the phalanges, by 
the circular or flap methods. At the metatarso-phalangeal 
articulations, by the oval method. 

Operation Throiiglt the articulation. — Single flap 

method Tiie toe being firmly grasped and flexed, a trans- 
verse incision is made wath a small narrow-bladed knife, 
cutting directly into the joint on the dorsal surface, over the 
most distinct fold which has been taken as a guide to the joint. 
The lateral ligaments are now to be divided, and the blade 
of the knife is introduced behind the head of the phalanx 
to be removed. The toe being extended, the knife is car- 
ried downward and forward toward the end in close contact 
with the bone, making a flap of the requisite length to cover 
the end of the bone. The digital arteries are, if necessary, 
52 



614 AMPUTATIONS. 

ligatured, the nerves and tendons retrenched, and the flap 
brought up over the end of the bone, and held in apposition 
by means of sutures. 

Circular method — Amputation may be performed by 
this method through the articulation by making an incision 
three or four lines below, dividing the skin. Dissecting 
this up to the joint, the ligaments are divided and dis- 
articulation effected. The cuff of skin is approximated in 
the transverse direction. 

Amputation in the Continuity of the Bones 

Either the circular or flap method may be employed in 
performing this operation. The incision being made and 
the flaps formed, as above described, the bone is divided with 
the small saw or cutting pliers. The flaps are held in 
apposition by sutures, applied as in the other forms. 

Amputation through the Metatarso- phalan- 
geal Articulation By the Oval method. 

OrERATiON The toe being flexed, the incision is made 

on the dorsal surface one-quarter of an inch above the joint, 
and carried obliquely down to the commissure, then across 
the plantar surface to the opposite side, the toe being 
extended, and thence obliquely upward to the point of 
departure. The extensor tendon, the lateral ligaments, and 
flexor tendons are to be divided in the order named, effecting 
disarticulation. The vessels are ligatured, the tendons and 
nerves retrenched, and the edges of the wound approximated 
in a linear direction. In this operation the head of the 
metatarsal bone may be removed, if deemed necessary. 

Amputation of the Great Toe — By the Oval method. 

Operations 1. This operation is performed by an 

incision beginning on the dorsum of the foot one-quarter of 



AMPUTATION OF THE GRKAT TOE. 



615 



an inch above tlie joint, and then carrying it obliquely down- 
ward and for^Yard on the outer side of the toe to the com- 
missure of the toes, then under the toe to the outer side, and 
terminating at the point of departure. 

Fiff. 333. Fig. 334. 




1, 2, 3, 4. Line of incision for removing first 
metatarsal bone with great toe. 

The flap is dissected up to the joint, the extensor ten- 
dons, lateral ligaments, and the flexor tendons are divided, 
completing disarticulation (Fig. 333). The arteries are liga- 
tured, the tendons retrenched, and the flaps approximated in 
a linear direction. In this operation the expanded extremity 
of the first metatarsal bone may be removed by the saw, the 
section being made obliquely through the bone from within 
outward, or the entire bone maybe dissected out, the incision 
being carried up to the tarso-metatarsal articulation (Fig. 
334). 

2. The great toe may also be removed by making a 
straight incision on the inner surface of the foot, beginning 
one-half of an inch above the joint, and carrying it down- 
ward to the middle of the first phalanx. From the termina- 
tion of this incision, a sliglitly curved incision is made on 
the dorsal surface to the commissure of the toes, and then 
one is made in a similar way on the plantar surface, joining 
the one first made. These flaps are dissected up to the joint, 



616 



AMPUTATIONS. 



disarticulation effected, and sutures applied so as to bring 
the edges together in a transverse direction. In performing 
these operations, care should always be taken to secure 
ample flaps to cover the large surface which the head of the 
first metatarsal bone presents. 

Amputation of the Little Toe By the Oval 

method. 

Operation — This toe can be removed by incisions made 
in the same manner as those employed to effect disarticula- 
tion of the great toe. 

Amputation of all of the Toes. — By the Flap 
method. 

Operation. — Fix the positions of the articulations (Fig. 
332), and make a semilunar incision a short distance in 
front of them, carrying it from one side to the other (Fig. 
335). A short flap is then dissected up, the joints exposed, 
and opened by dividing the extensor tendons and lateral 



Fiff. 335. 



Y\cr. 336. 





ligaments. The knife is passed behind the phalanges (Fig. 
336), and the flap, of requisite length, is made from the 
plantar surface (Fig. 337). The vessels are ligatured, the 



AMPUTATION OF THE METATARSAL BONES G17 

Fiff. 337. Fiff. 338. 





tendons retrenched, and the plantar flap is drawn up over 
the ends of the metatarsal bones, and secured by suture to 
tlie dorsal flap. Fig. 338 shows the stump after this opera- 
tion. 

Amputation in the Continuity of the Metatar- 
sal Bones. — By the Flap method. 

Operation Amputation through the metatarsal bones 

is performed by making a semilunar incision on the dorsum 
of the foot, a short distance below the point of section of the 
bones, dividing all of the tissues to the bones. Dissect up 
the integuments to a slight extent, and form a plantar flap 
by transfixion, introducing the knife, carrying it, in close 
contact with the bones, to the commissure of the toes. The 
flaps are retracted by a six-tailed retractor, four of the tails 
being passed through the four interosseous spaces, and the 
bones divided by the metacarpal saw. The vessels are liga- 
tured, the tendons on the dorsal and plantar surfaces re- 
trenched, and the plantar flap placed over the divided ends 
of the bones and secured to the dorsal flap by sutures. 

52* 



618 



AMPUTATIONS. 



Amputation at the Tarso-metatarsal Articu- 
lation. — By the Flap method (Lisfranc's operation). 

Bones. — The bones entering into the formation of the 
articulation are the internal, middle, and external cuneiform, 
articulating in order with the first, second, and third meta- 
tarsal bones, cuboid articulating with fourth and fifth meta- 
tarsal bones. 

Ligaments. — The ligaments are the dorsal, plantar, and 
interrosseous. 

Line of the articulation — A line drawn from a point 
behind the tuberosity of the fifth metatarsal bone across the 



Fig. 839. 



Fiff. 340. 





dorsum of the foot, to a point one inch in front of the tuber- 
osity of the scaphoid bone. 

Operation — Grasping the foot firmly, a curvilinear 



AT TiiK tarso-:metatarsal articulation. 



619 



incision, dividing tlie skin and fascice, should be made, with 
a strong scalpel, over the dorsum of tlie foot between tlie 
points above given, passing a short distance below the line 
of the articulation (Fig. 339). The skin and fascias should 
be dissected up to a slight extent, and another incision, 
across the foot, on a level with the edge of the retracted 
skin, should be made, dividing the remaining structures 
down to the bones. The dorsal ligaments should now be 
divided from the fifth to the second metatarsal bone, then 
the dorsal ligament connecting the first metatarsal bone to 
the internal cuneiform, and lastly, the dorsal ligament be- 
tween the second metatarsal bone and the middle cuneiform, 
bearing in mind that the line of the articulation between the 
second cuneiform bone and the second metatarsal bone is 
one-third of an inch above the others (Fig. 340). The 
knife, being held at an angle of 45° to the axis of the foot, 

Fig. 341. 




with the edge turned upward, should now be introduced be- 
tween the first and second metatarsal bones, and carried up 
with its point by this movement 



to a right angle, dividin 



620 



AMPUTATIONS. 



the ligament which binds the head of the second metatarsal 
bone to the outer surface of the first cuneiform bone (Fig. 
341.) Complete division being effected by giving the knife 
a rocking motion, it is withdrawn and applied in the same 



Fiff. 342. 



Fig. 343. 





Fig. 344. 



manner between the second and third metatarsal bones, and 
the head of the second metatarsal 
bone separated from the inner surface 
of the third cuneiform bone. De- 
pressing the foot firmly, the joint is 
opened and the remaining attach- 
ments can be divided. The plantar 
ligaments and the tendons of the 
peronei muscles should now be 
divided. An amputating knife is 
then introduced beneath the heads 
of the metatarsal bones (Fig. 342), 
and a flap made from the sole of the 
foot by carrying the knife forward 




AT THE tarso-:metatarsal articulation. 621 

in close contact ^\\ih tlie surfaces of the bones, care being 
taken to avoid the sesamoid bones of the great toe. The 
flap sliould be terminated at the roots of the toes by a 
broadly convex border (Fig. 3-13). 

The dorsalis pedis in the ujiper, and the two plantar 
arteries in the lower flap are divided, and may require the 
application of a ligature. The tendons being retrenched, 
the plantar flap is brought up over the exposed surfaces of 
the bones of the tarsus, and united to the upper flap by 
sutures. In Fig. 344 the stump after amputation by this 
method is shown. 

Amputation at the Tarso-metatarsal Articu- 
lation (Hey's operation.) 

This operation is a modification of that just described, and 
differs from it in the method of forming the flaps and in the 
section of the internal cuneiform bone. 

Operation A transverse incision, dividing the struc- 
tures to the bone, is made across the foot, extending from 
the tuberosity of the fifth metatarsal bone to a point mid- 
way between the head of the first metatarsal bone and the 
tuberosity of the scaphoid. From the extremities of this 
incision, lateral incisions are made to the toes, and are con- 
nected by an incision across the sole of the foot, disarticulating 
the toes. A flap from the sole of the foot is dissected back 
to the articulation, and disarticulation of the second, third, 
fourth, and fifth metatarsal bones effected by dividing the 
dorsal, plantar, and interosseous ligaments. The separation 
is now completed by dividing with the saw the projecting 
portion of the internal cuneiform bone. The remaining 
steps of the operation are performed in the same manner as 
described in Lisfranc's operation. 



022 



AMPUTATIONS. 



Section of the second metatarsal, instead of the internal 
cuneiform bone, has been practised in amputation at the 
tarso-metatarsal articulation. Also, disarticulation of the 
first metatarsal bone, and section of the remainder on a 
level with the internal cuneiform. 

Amputation at the Medio -tarsal Articulation. 

— By the flap method (Chopart's operation). 

Bones The bones entering into the formation of the 

articulation, on the inside, are the astragalus behind with 
the scaphoid in front ; outside, os calcis behind, with the 
cuboid in front (Fig. 345). 



Fig. 345. 



Fiff. 346. 




1. Astragalus. 

2. Os calcis. 

3. Cuboid. 

4. Scaphoid. 




Ligaments Dorsal — superior astragalo-scaphoid, supe- 
rior calcaneo-scaphoid, superior calcaneo-cuboid, and inter- 
nal calcaneo-cuboid or interosseous. t*lantar — inferior 
calcaneo-scaphoid, long and short calcaneo-cuboid. 

Line of articulation A line drawn across the dorsum 

of the foot from a point one-half to three-quarters of an inch 



AT TIIK MEDIO-TAKSAL ARTICULATION. 



623 



behind the head of the fiftli metatarsal bone to a point one 
inch in front of the internal malleolus, or immediately 
behind the tubercle on the scaphoid bone. This line will 
be three-quarters of an inch in front of the ankle-joint. 

Operation Grasping the foot with the left hand so 

that the thumb and index finger shall rest at the points 
given on the inner and outer side of the foot, indicating the 
position of the articulation, the knife, a strong scalpel, 
should be carried across the dorsum of the foot, making a 
short, slightly convex flap (Fig. 346). Dissecting up the 
integuments to a slight extent, a second incision should be 
made on a level with the retracted flap, dividing the remain- 
in": structures down to the bones. Fixing the line of the 
articulation, the dorsal and interosseous ligaments are 
divided, exposing the joint fully. Dividing the plantar 



Fi?. 347. 



Fig. 348. 





ligaments, an amputating knife is placed beneath the bones 
(Fig. 347), and a flap of suflicient length made from the 
sole of the foot (Fig. 348). The arteries which are divided 



624 



AMPUTATIONS. 



Fig. 349. 



in this operation are the dorsalis pedis in the dorsal flap, 
and the plantar arteries in the plantar flap. The tendons 
are retrenched, and the plantar is attached to the dorsal flap 
by means of sutures. 

In this operation attention is directed to the importance 
of making the lateral incisions low down upon either side, 
so as to pass the knife readily under the bones, and of 
giving an oval shape to the border of 
the plantar flap. In seeking the line of 
the articulation, it is desirable to avoid 
o-ettincr too far back, so as to reach the 
line between the astragalus and os cal- 
cis, and equally desirable to avoid 
advancing so far forward as to get 
between the scaphoid and cuneiform 
bones. The convex and rounded articu- 
latincr surface of the astrasjalus is to be 
distinguished from the articulating sur- 
face of the scaphoid, which shows three 
distinct impressions, which receive the articulating surfaces 
of the three cuneiform bones. The stump after union has 
occurred is shown in Fig. 349. 

By the flap method. (Tripier's operation.) — Commencing 
at the outer edge of the tendo Achillis, on a level with the 
external malleolus, an incision through the integument is to 
be made in a direction at first downward and forward, and 
afterwards forward, passing two fingers' breadth below the 
malleolus, and then approaching by a finger's breadth the 
upper part of the base of the fifth metatarsal bone (Fig. 
350). From this point the incision is to be carried upward, 
forward, and inward, so as to reach the inner margin of the 
tendon of the extensor proprius pollicis, just behind the first 




AT THE MEDIO-TAUSAL ARTICULATION. 



C25 



tarso-metatarsal articulation. The knife slioulcl now be made 
to cut downward and forward, so as to enter the sole of the 
foot a finger's breadth in front of the dorsal incision. The 
incision is then to be carried with a gentle forward curve, 
outward and backward, until it can be made continuous with 
the first portion of that below the outer malleolus (Fig. 351). 
The divided integument having undergone some degree of 



Fis. 350. 





retraction the dorsal and plantar structures are to be divided 
half an inch behind the superficial incision ; the soft parts 
are then to be separated from the bones, extreme care being 
taken to preserve uninjured the vessels contained on the 
inner part of the plantar flap. At this stage, the cuboid and 
scaphoid sliould be disarticulated from the os calcis and 
astragalus, the periosteum then divided and separated from 
the under surface and posterior extremity of the os calcis 
up to the level of the sustentaculum tali where the bone is 
to be sawn through in a direction from behind and within, 
53 



6-26 



AMPUTATIONS. 



forward and outward, so as to leave a surface which will 
be at right angles with the axis of the tibia when the limb 
assumes the position for walking or standing (Fig. 352). 



Fig. 352. 




Fig. 353. 




All sharp bone edges and angles should be rounded off. 
The posterior tibial nerve is to be retrenched to avoid 
danger of neuroma, and the wound dressed so as to secure 
moderate flexion of the ankle-joint during repair (Fig. 353). 



Amputation at the Tibio-tarsal Articulation 

By thejiap method (Syme's operation). 

Bones. — The bones entering into the formation of the ar- 
ticulation are the lower extremity of the tibia on the inside, 
terminating in the internal malleolus, and the lower extrem- 
ity of the fibula on the outside, terminating in the external 
malleolus, embracing the broad trochlear surface of the as- 
tragalus, and forming a true ginglymoid joint free from 
lateral motion. 

Ligaments The ligaments of the articulation are the 

anterior, the internal lateral or deltoid, and the external 
lateral, consisting of three fasciculi. The transverse Hofa- 



AT THE TIBTO-TARSAL ARTICULATIOX. 



027 



ment of the tibia and fibula supply the place of a posterior 
ligament to the joint. 

Lines of incision. — First. — From the centre of the outer 
malleolus, downward and across the sole of the heel, in a 
straight line ; then upward to a point on the same level of 
the opposite side, a slight distance below and behind the 
extremity of the inner malleolus (Figs. 354, 355). 

Second. — An incision across the instep, connecting the 
points of the first incision. 

Operation — The leg being supported, and the foot 
placed at right angles to the leg, an incision should be made 
with tlie scalpel 

from the outer Fig. 354. 

malleolus to a 
point on the same 
level of the oppo- 
site side, a slight 
distance below and 
behind the extre- 
mity of the inner 
malleolus, across 
the heel, dividing 
the structures 

to the bone, in 
the line indicated. 
The anterior in- 
cision across the 
instep should be 
next made, and 
the posterior flap 
dissected from the 
surface of the os calcis, the knife being kept in close con- 




Fig. 355. 




628 



AMPUTATIONS. 



contact with the bone, so as to avoid wounding the blood- 
vessels and transfixing the flap (Fig. 356.) This can be 
accomplished by placing the fingers of the left hand upon 
the heel, the thumb resting upon the edge of the integument, 
and keeping the knife between the thumb-nail and the sur- 

Fig. 356. 




face of the bone, at the same time pressing back the tissues 
as they are detached. The tendo Achillis, when exposed, 
should be divided, and disarticulation effected by cutting 
into the joint on the dorsum, and the sides of the foot at the 
margin of the anterior flap. The tissues are dissected up- 
ward so as to expose the malleoli fully, the knife carried 
around so as to divide the periosteum, and the saw applied, 
removing a thin slice of the tibia with the two malleoli. 

The arteries divided in this operation and requiring liga- 
ture are the dorsalis pedis on the dorsal surface, and the two 
plantar. The tendons having been retrenched, the posterior 



AT THE TIBIO-TARSAL ARTICULATION. 



G29 



is to be placed in apposition with the Fig. 357. 

anterior flap and secured by sutures, 
and an opening made in the posterior 
flap to secure drainage. 

In performing this operation, the 
surgeon should bear in mind the im- 
portance of keeping the knife close to 
the bone in dissecting off the posterior 
flap, in order to avoid wounding the 
vessels which nourish the tissues, and 
also to avoid puncturing the flap, which, 
where it is in contact with the tendo 
Achillis, is very thin and closely adher- 
ent. The character of stump formed after this operation is 
shown in Fig. 357. 




Amputation at the Tibio-tarsal Articulation 

(Pirogoff's operation). 

This operation is a modification of Syme's method, and 
consists in leaving the posterior portion of the os calcis in 
the heel flap, and placing it in apposition with the surfaces 
of the tibia and flbula, the articulating surfaces of which 
have been removed. 

Operation. — The incisions, in this operation, are made 
in the same manner as in »Syme's operation, the lines of sec- 
tion through the integument (b) and the bones (a, c) being 
shown in Fig. 358. The articulation is opened from the 
front, and the lateral ligaments divided, thus disarticulating 
the head of the astragalus. A small narrow -bladed saw, or 
a saw such as is used in excisions, is placed obliquely upon 
the OS calcis behind the astragalus, exactly upon the lesser 
process of the bone, or sustentaculum tali, and section of the 

53* 



630 



AMPUTATIONS. 



bone is made following the line indicated («) in Fig. 358. 
Tlie malleoli are next exposed and removed by the saw, the 

Fig. 358. 




tendons are retrenched, and the posterior flap containing 
the segment of the os calcis is now brought up and attached 



Fiff. 359. 




AMPUTATIONS OF THE LEG 



631 



to the anterior flap, placing the bony sur- 
faces in apposition. 

The direction given to the line of sec- 
tion of the OS calcis in this operation is a 
matter of importance, in order that the 
bones may be brought accurately into ap- 
position. Care should be taken to avoid 
making the section too oblique and also 
in beginning the section too near the astra- 
galus. Fig. 360 represents the stump 
formed after this method of amputation. 




Amputations of the Leg. — Surgical Anatomy. — 
The leg is that portion of the lower extremity which extends 
from the thigh to the foot, and may be divided into the 
upper, middle, and lower third. 

Bones. — The bones which enter into its formation are tlie 
Patella, the Tibia, and the Fibula. 

The Patella is a large sesamoid bone placed in front of 
the knee-joint. Its purpose is to protect the front of the 
joint and to increase the leverage of the extensor quadriceps 
femoris muscle. 

The Tihia is a large prismoidal-shaped bone placed on 
the inside of the leg, entering by an expanded upper ex- 
tremity into the formation of the knee-joint, and below into 
the ankle-joint by its lower extremity, the internal malleolus. 
It presents on its anterior surface a sharp crest which lies 
subcutaneous in its entire extent. 

The Fibula is a long slender bone occupying a position 
on the outside of the leg, articulating by its upper extremity 
with the tibia, and below terminating in the outer malleolus, 
which forms part of the ankle-joint. 



632 AMPUTATIONS. 

Ligaments — The tibia and fibula are united by the inter- 
osseous ligament, and are connected to the astragalus below 
by the ligaments already described (page 626). 

Muscles — On the inner side of the anterior surface the 
tibia is placed, its crest being subcutaneous. In the middle 
and on the outer or fibular side of this surface the tibialis 
anticus, extensor proprius poUicis, extensor longus digito- 
rum, and peroneus tertius muscles are situated. Two layers 
of muscles occupy the posterior surface ; the gastrocnemius, 
soleus, and plantaris muscles being superficial and forming 
the '^ calf." The deep layer consists of the popliteus, flexor 
longus pollicis, flexor longus digitorum, and tibialis posticus. 
On the fibular surface the peroneus longus and brevis are 
placed. 

Bloodvessels The anterior and posterior tibial and the 

peroneal arteries pass down on the anterior and posterior 
surface of the leg, the anterior tibial lying on the anterior 
surface of the interosseous ligament until it reaches the 
lower part of the leg, while the posterior tibial and peroneal 
arteries rest upon the posterior surface of the posterior tibial 
muscle. 

Nerves The anterior tibial and musculo-cutaneous 

nerves are distributed to the anterior surface of the leg, 
while the posterior tibial and peroneal supply the posterior 
and outer surface (Fig. 361). 

Amputation may be performed in either the lower, mid- 
dle, or upper third of the leg, and by the circular, oval, 
rectangular, single or double flap methods. The circular 
and rectangular methods are best adapted for the lower 
third, the modified circular or flap methods are preferable 
in the middle and upper third. Amputation of the leg 
should never be performed above the tubercle of the tibai 



AMPUTATIONS OF THE LEG — LOWER THIRD. 



633 



or the points of insertion of the biceps, semi-tendinosus, and 
semi-membranosus muscles, which are necessary in control- 
ling the movements of the stump. The point of election, or 
the most desirable point for removal of the leg, is from two 
to two and a half inches below the tuberosity of the tibia. 



Fiff. 361. 



1. Tibialis posticus mus- 
cle. 

2. Tibialis anticus muscle, 
i Flexor longus digito- 

rum. 
4. Extensor longas digito- 

rum. 
6. Internal saphenous 

vein. 

6. Anterior tibial vessels 
and nerve. 

7. Tendon of the plautaris 
muscle. 

8. Peroneous longus mus- 
cle. 

9. Posterior tibial vessels 
and nerves. 

10. Flexor longus pollicis. 

11. External saphenous 
vein and nerve. 

12. Soleus muscle with fi- 
brous intersection. 

13. Peroneal vessels, 

14. Gastrocnemius muscle. 

15. Communicans peronei 
nerve. 




Section of the Right Leg in the upper third, 
showing structure. 



Operation — In the loiver third Three to three and 

one-half inches above the ankle-joint. 

By the circular method — The limb being supported by 
an assistant, the proximal part is grasped by the left hand 
of the operator, the skin firmly retracted, and the ampu- 
tating knife is carried around the limb, making a circular 



634 



AMPUTATIONS. 



incision (Fig. 3G2, a), dividing the skin and superficial 
fascia in the manner already described (page 581). The 

cuff of skin and 
^^' ' fascia is dissected 

up to the extent of 
one and one-half to 
two inches and turn- 
ed back. Guard- 
ing carefully the 
margin of the re- 
tracted cuff, a cir- 
cular incision is 
made around the 
limb at this point, 
dividing the mus- 
cles and other struc- 
tures to the bones. 
Tliese, with the pe- 
riosteum, are dis- 
sected back to the 
extent of an inch 
or more, and the interosseous membrane divided with the 
catlin or a large scalpel. A three-tailed retractor is now 
applied, the middle tail being passed through the inter- 
osseous space from below upward and the tissues firmly re- 
tracted. The saw, held in a vertical position, should be 
applied to both bones, drawing it from heel to point and 
dividing them by short, even strokes, care being taken that 
the fibula, which is the smaller and most movable bone, 
should be divided first. 

The anterior and posterior tibial and peroneal arteries 
are divided and require ligature. The anterior tibial artery 




AMPUTATIONS OF THE LEG — LOWER THIRD. 635 

at this point lies in front of the tibia. The posterior tibial 
and peroneal arteries should be sought for in the interspace 
between the soleus muscle beliind, and the tibialis posticus 
muscle in front, the former lying somewhat behind the tibia, 
and the latter along the inner border of the fibula. The 
vessels having been ligatured, the tendons and nerves re- 
trenched, the cufF is drawn down and the edges approxi- 
mated by sutures in the transverse or vertical direction. 

In amputations of the leg it is desirable to remove the 
sharp point formed by the crest of the tibia after section. 
This should be done with the saw or bone pliers, cutting 
obliquely from above downward. 

In the lower third. By the rectangular method (Teale's 
operation). 

Operatiox. — The lines of incision having been traced 
out on the limb, the knife is introdced on one side at the 
point of intended section of the bones and carried downward 
to a distance equal in length to one-half or one-third the 
circumference of the limb, dividing all of the structures to 
the bone (Fig. 326). A similar incision is made on the 
opposite side, and the two are united by one made trans- 
versely across the anterior surface of the leg. The flap, 
containing the skin and muscular structures, is now dissected 
up, care being taken to avoid wounding the anterior tibial 
artery at the base of the flap. The posterior flap, equal in 
length to one-eighth the circumference of the limb, or one- 
fourth the length of the anterior flap, is made by a circular 
incision down to the bone. This flap is dissected up to the 
requisite extent, the interosseous membrane is divided, the 
retractor applied, and the bones sawn (Fig. 327). The 
vessels having been ligatured, the tendons and nerves re- 



636 AMPUTATIONS. 

trenched, the long flap is turned over the ends of the bones 
and attached to the short flap by sutures (Fig. 328). 

In the middle and tipper third. By the double-flap 
method Antero-posterior. 

Operation. — The limb being supported, the operator 
grasps the proximal part (placing the thumb and index 
finger at the points on the outer and inner surfaces of the 
leg, so as to indicate the breadth of the flap, as well as the 
point of section of the bone), retracts the skin, and makes a 
semilunar incision, either with the scalpel or small ampu- 
tating knife, across the front of the leg from the inner edge 
of the tibia to the outer edge of the fibula, dividing skin and 
superficial fascia. This flap, which should be one-fourth the 
length of the posterior and cutaneous in character, is dis- 
sected up to the requisite extent, and, the leg being flexed 
slightly, the amputating knife is entered at the external 
angle of the first incision and made to transfix the structures 
on the posterior part of the leg, emerging at a point corres- 
ponding on the opposite side of the leg (Fig. 363). In 

Fig. 363. 




passing the knife, care sliould be taken to avoid carrying its 
point betiveen the bones. This is likely to occur, unless the 
operator bears in mind that the edge of the fibula is on a 
plane posterior to that of the tibia, and, therefore, the 
handle of the knife should be elevated in order to depress the 
point as it passes behind the bone. The knife, having 



AMPUTATION AT THE KNEE-JOINT. 037 

transHxed the tissues, is carried downward in close contact 
with the surface of the bones, forming a flap of at least four 
inches in lengtli. The flaps are now drawn back, the re- 
maining structures and interosseous membrane divided, the 
retractor applied, and the bones sawn. 

The anterior and posterior tibial and peroneal arteries 
will require ligature — possibly some of the larger muscular 
branches. Sometimes difficulty is experienced in sur- 
rounding the anterior tibial artery with a ligature, owing 
to its retraction above the section of the interosseous mem- 
brane upon which it lies. Extension of the limb will 
frequently cause it to project, so that it can be seized and 
ligatured. 

The vessels having been ligatured, and the tendons and 
nerves retrenched, the flaps are approximated by sutures. 

By the lateral double-flap method Long external and 

short internal flap (Sedillot's operation). 

Operation. — The limb being flexed and the foot ex- 
tended, the skin is elevated over the point of intended sec- 
tion, and the amputating knife is introduced midway between 
the crest of the tibia and the fibula, and, passing external to 
the latter, is brought out in the calf of the leg (Fig. '6^2, c). 
Cai-rying it downward in close contact with tlie external 
surface of the bone, a long external flap is formed. A 
transverse incision, slightly convex forward, divides the 
tissues on the inside of the leg. Dissecting up this flap to 
the requisite extent, the interosseous membrane is divided, 
the retractor applied, and the bones sawn as described in the 
other operations. 

Amputation at the Knee-joint Surgical An- 
atomy Tiie knee is a ginglymoid or hinge-joint, composed 

54 



638 AMPUTATIONS. 

of three bones, the condyles of the femur above, the patella 
in front, and the upper extremity of the tibia below. The 
bones are united by fourteen ligaments, anterior, lateral, 
posterior, and internal, the more important of which are — 

The anterior or ligamentum patellce, a portion of the ten- 
don of the extensor quadriceps femoris, measuring three 
inches in leno-th, and extendinoj from the lower border of 
the patella to the point of insertion in the tuberosity of the 
tibia. 

The lateral ligaments are the internal, and the long and 
short external. 

The posterior, or the ligamentum posticum Winslowii, 
covers over the entire posterior portion of the joint, and is 
formed of dense fibrous tissue. 

Of the ligaments within the joint, the two crucial, anterior 
and posterior, and the two semilunar Jibro-cartilages, the 
internal and external, are the most important in the surgical 
point of view. 

The crucial ligaments are strong interosseous bands at- 
tached, below, to the spine of the tibia, and, above, to the 
outer and inner condyles of the femur, crossing each other 
as they pass from below upward, the anterior being attached 
to the front of the spine of the tibia and the inner surface of 
the outer condyle, and the posterior to the back of the spine 
and the outer surface of the inner condyle. 

The semilunar fibro-cartilages are two crescentic lamellae 
attached to the borders of the head of the tibia, and serve 
to deepen the surface for articulation with the condyles of 
the femur. 

The tendons of the powerful muscles of the thigh, with 
some of the muscles of the leg, surround and protect it, 



AMPUTATION AT THE KNEE-.TOTNT. 



G39 



Fig. 364. 




while important bloodvessels and nerves have intimate rela- 
tions with the joint (Fig. 3G4). 

The condyles of the femur are two large eminences, into 
which the lower extremity divides. The external condyle 
is the more prominent anteriorly, and 
broader, while the internal is most 
prominent internally, and narrower. 
It is to be remembered that they are 
not on the same level, the internal being 
nearly one-half of an inch lower than 
the external. The tuberosity on the 
outer surface of the external condyle 
is less prominent than that on the 
internal. The line of the articulation 
may be described as extending inter- 
nally from a point three-quarters of an 
inch above the tuberosity of the tibia, 
across the lower border of the patella, -^ '^^^ patella. 

4. The crucial ligaments. 

and terminating externally three- 
quarters of an inch below the prominence of the condyle of 
the femur. 

Amputation through the knee-joint may be performed by 
either the flap, circular, or oval methods. Of the flap 
methods, that by the long anterior and short posterior is 
preferred. 

Amputation hy the long anterior and short posterior Jiap 
method, retaining the Patella. 

Operation — The knee being flexed, an incision is made, 
with the scalpel or small amputating knife, from a point on 
a line with the condyle, near to the border of the popliteal 
space, across the front of the leg, two and one-half inches 
below the tubercle of the tibia, to a point corresponding on 



Vertical Section of the 
Knee-joint. 

1. The femur. 

2. The tibia. 



640 



AMPUTATIONS. 



Fig. 365. 



the opposite side. Dissecting up this flap, tlie ligamentiim 
patellae and the lateral ligaments are divided, opening the 

joint. The crucial liga- 
ments are next divided, and 
any remaining portions of 
the lateral ligaments, thus 
completely exposing the 
joint. The amputating 
knife is now placed behind 
the head of the tibia, and a 
short posterior flap is made 
by cutting downward, keep- 




ing the knife in close con- 



tact with the bone, care 
being taken to avoid the 
head of the fibula. The 
popliteal artery will require 
ligature, and possibly several 
of its branches (Fig. 365). 
It lies in close contact with 
the posterior surface of the 
posterior ligament of the 
joint, and should be sought 
ibr in this position. The 
tendons and nerves are retrenched, and the anterior flap 
drawn down over the condyles of the femur, and attached to 
the posterior by sutures. 

The importance of keeping near to the margins of the 
popliteal space is to be borne in mind, in order that a flap 
of sufficient size may be secured to cover the large articulat- 
ino- surfaces of the condyles of the femur. 



The Popliteal Artery and its Branches 
in relation with the Kuee-joiut. 

1. Femur. 

2, 3. Condyles of femur. 

4. Popliteal artery. 

5, 6, 7. Superior articular b- aches. 
S, 9. Inferior articular Lranche.s. 

10, 11. Sural branches. 



AMPUTATION AT THE KNEE-JOINT. 



G41 



By the short anterior and long posterior flap — Tliis 
method of amputation may also be employed, in which case 
the patella is removed, and also the condyles of the femur, 
the long flap being taken from the muscles forming the calf 
of the leg (Figs. 3GG, 3G7). 



Ficr. 3(j6. 



Fi<?. 367. 




Short Anterior aad Long 

Posterior Flap. 

1,2,3. Line of incision 

for anterior flap. 




Short Aatei'ior and Loag Posterior Flap. 
1, 2, 3. Liae of inci-sion for posterior flap. 



By the circular method The circular method may be 

employed in affecting disarticulation, the first incision 
being carried around the limb, through the integument, 
three or four fingers' breadths below the patella. This flap 
is dissected up to the line of the articulation, and disarticu- 
lation effected by division of the ligamentum patellae, the 
lateral ligaments, the crucial and, fi.nally, the posterior 
ligament (Fig. 368). The edges of the flaps are united in 
either the transverse or vertical direction. 



642 



AMPUTATIONS. 



By the oval method (Bauden's method). — This operation 
is described as follows — The knife is entered three fingers' 
breadths below the tuberosity of the tibia, cutting at first 
transversely, then obliquely upward and around the limb to 
a point in the popliteal space two fingers' breadths below 
the line of tlie joint ; the incision passes transversely across 
the back of the limb, and is continued obliquely downward 



Fig. 368. 



Fig. 3fj9. 





Circular Method. 
1, 2, 3. Section of integuments. 
4, 5. Keiiected integuments. 



The Oval Method. 
1, 2, 3. Oblique section of the integument! 
4, 5. Eeflected integuments. 



to its point of commencement. This oval flap is dissected 
up, and disarticulation effected by dividing the ligaments of 
the joint (Fig. 369). The vessels are ligatured, and the 
edges of the flap approximated by sutures. 



Amputation of the Thigh — Surgical Anatomy. 
— Tlie thigh is that part of the lower extremity which 



A]MPlTTATION OF THE TIIICIT. 043 

extends from tlie pelvis to the leg, and may be divided for 
the purposes of am[)Utation intcrthe upper, middle, and lower 
thirds. It is larger above than below, and has the shape of 
an inverted and truncated cone. It is composed of one 
large bone, numerous large and powerful muscles, blood- 
vessels, nerves, and lymphatics, and is covered by the integu- 
ment, superficial fascia, and a strong aponeurosis (fascia 
lata). 

Bone Tlie bone of the thigh, the femur, is the largest, 

longest, and strongest bone in the skeleton. The superior 
extremity is divided into a globular head which enters into 
the formation of the hip-joint, a neck varying in length and 
obliquity, and two prominent processes, the trochanters — 
tlie greater on the outside and the lesser on the inside. 
Tlie inferior extremity terminates in the condyles which 
form part of the knee-joint. 

Muscles. — Large and powerful muscles occupy the ante- 
rior, internal, and posterior surfaces of the thigh ; on the 
anterior surface the tensor vaginoe femoris, sartorius and 
quadriceps extensor femoris, and subcrureus ; on the inter- 
nal surface the gracilis, pectineus and adductors longus, 
brevis, and magnus ; on the posterior surface the biceps, 
semitendinosus, and semimembranosus. Attached to the 
inner trochanter is the common tendon of the psoas magnus 
and iliacus, while to the outer trochanter and upper part of 
the shaft are the glutei, the pyriformis, the two obturators, 
the two gemelli, and quadratus femoris. 

Bloodvessels. — The femoral artery, and branches of the 
internal iliac, supply the structures of the thigh ; the for- 
mer in its course down the thigh passes from the anterior 
to the inner, and then to the posterior surface ; the latter 
escape from the pelvic cavity through the great sciatic fora- 



644 



AMPUTATIONS. 



men, and supply the structures in the region of the hip- 
joint. 

Nerves The anterior crural and the great and small 

sciatic nerves with their branches, are distributed to the 

Fig. 370. 




Section of the Right Thigh a 
showiu! 

Profuudii feniori.s vessels. 
Adductor longus muscle. 
Femoral vessels. 
Superficial obturator nerve. 
Sartorius muscle. 
Gracilis muscle. 
External cutaneous nerve. 
Pectineus muscle. 
Rectus femoris muscle. 
Adductor brevis muscle. 
Anterior crural nerve. 
Deep obturator nerve. 



t the apex of Scarpa's Triangle, 
r structure. 

13. External circumflex vessels. 

14. Adductor magnus muscle. 

1.1. Tensor vagina; femoris muscle. 

16. Semimembranosus muscle. 

17. Vastus internus and crureus 

muscles. 

15. Semitendinosus muscle. 

19. Vastus exiernus muscle. 

20. Small sciatic nerve. 

21. Biceps muscle. 

22. Great sciatic nerve. 



structures of the thigh, the former occupying the anterior 
and inner aspect, and the latter the posterior and outer 
(Fig. 370). 



AMrUTATlON OF TIITCIT — TITROUOII CONDYLES. C)4i) 

Amputation may be performed at any point of the limb, 
and by either the circ'uh\r, oval, flap, or rectangular me- 
thod. The flap method is that which is usually preferred, 
owing to the ease with which it is performed and the com- 
plete covering it gives to the end of the bone. In perform- 
ing amputation by the flap method the tendency to powerful 
retraction on the part of the muscles of the thigh should be 
remembered, and the flaps made ample in order to avoid 
the formation of a conical stump. 

Amputation through the base of the condyles. By the 
single anterior Jiap method (Garden's method). 

Operation The anterior flap is made by carrying an 

incision from a point two inches above the tuberosity on 
the outer condyle of the femur, downward, forward, and 
inward across the anterior surface of the knee-joint, below 
the tubercle of the tibia, to a similar point above the tuber- 
osity on the inner condyle. The flap is dissected up from 
the patelhi, and the angles of the first incision are joined by 
a circular incision across the posterior surface carried to the 
bone. The flaps are retracted and the condyles removed 
through the base. The vessels are ligatui-ed, the nerves re- 
trenched, and the anterior flap is drawn over the bone and 
attached by sutures to the posterior incision (Fig. 371). 

Through the base of the condyles. By the long anterior 
and short posterior flap method (Gritti's method). 

Operation. — In the operation performed by this method 
the anterior flap is made by carrying an incision, from a 
point two inches above one condyle, across the knee, just 
below the tuberosity of the tibia to a corresponding point on 
tlie opposite side (Fig. 372 j. The flap, formed of the integu- 
ment and fascia, is dissected up, the ligamentum patellar 
divided and a thin section is removed by the saw from the 



646 



AMPUTATIONS. 



articulating surface of the patella. A short posterior flap 
is now formed joining the angles of the first incision. Tlie 
remaining structures are divided by a circular incision 
around the bone, the flaps retracted and the condyles sawn 



Fig. 371. 



Fig. 372. 





off througli the base. The vessels are ligatured, the nerves 
retrenched, and the flaps are approximated, the cut surfaces 
of the patella and femur being placed in contact. 

In the lower third. By the antero-posterior Jiap method. 

Operation. — The tissues on the anterior surface of the 
thigh being grasped firmly, raised and retracted, the ope- 
rator enters the amputating knife on the side of the limb 
nearest to him, carries the point directly to the centre of 
the bone, depresses the handle, passes the point over the 
bone and brings it out at a point on the opposite side cor- 
responding to the point of entrance. It is then carried 
downward in close contact with the surface of the bone to 



AMPUTATION OF THK THIGH LOWER THIRD. 647 

the distance of two to three inches as may be necessary, 
when its edge is turned and is made to cut its way out in 
an oblique direction. The knife is re-entered at the original 
point, carried behind the bone, emerging at the same point 
as before, and the posterior flap, which should be somewhat 
longer than the anterior, is formed by cutting downward 
and then outward as in forming the first flap ; a circular 
sweep is now made around the bone, dividing the remaining 
tissues, with the periosteum ; the latter is dissected up to a 
short extent, the retractor applied, and the bone sawn 
through. The arteries divided and requiring ligature are 
the femoral and some of its muscular branches. The artery 
is found on the inside under the sartorius, with the vein to 
the outside. 

The flaps are retrenched, if necessary, and united by 
sutures. 

In the lower third. By lateral flaps. 

Operation The tissues on the side of the limb being 

grasped so as to elevate and retract them, the knife is 
entered in the vertical direction, carried down to the bone, 
passing to one side, and emerging on the posterior surface 
of the thigh at a point exactly opposite that of entrance. 
It is then carried downward in close contact with the bone, 
and then outward, forming a flap from three to four inches 
in length as may be required. The knife is reintroduced 
at the same point, passed around the bone, and is brought 
out at the same point on the posterior surface of the limb, 
and a flap formed as before (Fig. 373, h). A circular sweep 
is made, dividing the remaining structures with the perios- 
teum, the latter is dissected up to a slight extent, the re- 
tractor applied, and the bone sawn through. The vessels 



648 



AMPUTATIONS. 



are ligatured, and the flaps united as in tlie operation by 
antero- posterior flap. 

In the lower third. By the long anterior Jiap. (Sedil- 
lot's operation.) 



Fi-. 3^ 




Operation — Amputation by this method is performed 
by making a flap from the anterior surface, equal in length 
and breadth at its free extremity to two-thirds of the cir- 
cumference of the limb at the point of section of the bone. 
This flap is made by transfixion, and should not include the 
artery. A slightly convex incision, dividing structures to 
the bone, is made on tlie posterior surface on a level with 
the base of the long flap. The operation is completed as in 
other methods. 

In the lower third. By the rectangular flap. 

Operation — The lines of incision having been traced 
out on the limb (Fig. 374), two longitudinal incisions are 
made on either side, beginning at the point of intended 
section of the bone, and carried downward to such extent 
as to form a flap measuring in length and breadth from one- 



AMrUTATION OF THE THIGH. 



G49 



tliiril to one-linlf tlie circumference of the limb. Tliese in- 
cisions are joined at their lower extremities by a transverse 
incision, and the flap, including all of the structures to the 
bone, is to be dissected up. The short or posterior flap, 
containing the vessels and equal in length to one-fourth of 
the long flap, is made by a transverse incision to the bone. 
This flap is dissected up, and, the retractor having been 
applied, the bone is sawn through (Fig. 327). The vessels 
are ligatured, and the sutures introduced, uniting tlie- flaps 
(Fig. 37o). 



Fiff. 374. 



Fi-. 375. 





In the hiver third. B\j the circular method. 

Operation — Amputation by this method is performed 

by making a circular sweep around the limb just above the 

upper margin of the patella (Fig. 373, «), dividing the 

skin and superficial fascia. Firm traction is made by an 

55 



6.50 



AMPUTATIONS. 



assistant, with both hands, in order to retract the integu- 
ments, and another circular incision is made, dividing the 
superficial muscles, the posterior being cut somewhat longer 
than the anterior. Retraction is again made, and the 
deeper muscles divided, by a circular incision, to the bone. 
The retractor is applied, the bone sawn, the vessels ligatured, 
and the operation completed by approximating the Hap with 
sutures. 

This method of performing the circular operation gives a 
complete covering to the end of the bone, which forms the 
apex of a hollow^ cone, the base being formed by the margins 
of the integuments. 

Fis:. 376. 




In the loiver third. By the modijied circular method. 

Operation — By tliis method, two semilunar flaps, with 
the convexity downward, consisting of skin and superficial 
fascia (Fig. 376), are dissected up to the point of section 



AMPrTATION AT THE MI I' -JOINT. 051 

of the bone, and an incision of the muscles made as in the 
circular operation just described. The semilunar flaps 
covering the muscles are united by sutures, as in the flap 
method. 

In the middle third Amputation at this point may be 

performed by any of the methods employed in the lower 
third. The retraction of the muscles being here less than 
in the lower third, the flap method can be adopted with ad- 
vantage (Fig. 373, c). 

In the upper thirds heloiv the trochanters At this point 

amputation by the antero-posterior flap is deemed the most 
desirable method, and is performed in the same manner as 
in tiie middle or lower third. 

Amputation at the Hip-joint. — Surgical Anat- 
omy. — The hip-joint is an enartlirodial or ball-and-socket 
joint formed by the reception of the globular head of the 
femur into the cup-shaped cavity of the acetabulum, placed 
on the outside of the os innominatum. 

Bones The bones which enter into the formation of the 

joint are the femur and the os innominatum, consisting of 
the ilium, ischium, and pubes. 

Ligaments. — The principal ligaments of the joint are the 
capsular — ilio-femoral and teres ; the cotyloid is a fibro-car- 
tilaginous rim which serves to deepen the cavity of the ace- 
tabulum, and the transverse is placed across the acetabular 
notch, converting it into a foramen. The capsular is a 
strong, dense ligament which envelops the joint, being at- 
tached above to the margin of the acetabulum, and below, 
around the base of the neck of the femur. The ilio-femoral 
is a re-enforcing or an accessory ligament extending ob- 
licpK'ly across the" front of the joint. The teres ligament 



652 AMPUTATIONS. 

consists of a triangular band of fibres, the apex of wliicli is 
inserted in a depression placed on the head of the femur a 
little behind and heloic its centre : the base is attached to the 
margins of the notch on the floor of the acetabulum. 

Muscles. — The joint is surrounded on all sides by large, 
strong muscles which cover and protect it. They take 
their origin in general from the different parts of the pelvis 
adjacent to the articulation, and are attached to the tro- 
chanters and upper portions of the shaft of the femur. 
They have been named in connection with tlie muscles of 
the thigh. 

Bloodvessels The bloodvessels which supply the joint 

are derived from the obturator, sciatic, internjil circumflex, 
and gluteal arteries. The femoral arteiy passes in front of 
the articulation, separated by the capsular ligament and the 
inner margin of the psoas magnus muscle, upon which it rests. 

Nerves Branches from the saei'al plexus, the great 

sciatic, obturator, and accessory obturator supply the joint 
(Fig. 377). 

The articulation being placed deeply beneath the mus- 
cular and other structures, and therefore difficult to reach 
by manipulation, it is important to establish the positions 
and relations of certain fixed points. Bernaid and Huette 
give the following guides to the articulation, wliich should 
be borne in mind in operations upon the joint. 

1. The anterior interior S[iinous process of the ilium is 
three-quarters of an inch above the superior margin of the 
acetabulum ; the anterior superior spinous process is about 
an inch and three-quarters above the same point, and three- 
quarters of an inch to its outer side. 

2. The subject being erect, a line drawn from the ante- 
rior superior spinous process of the ilium to tlie tuberosity 



AMTUTATION AT THE IITP-.TOINT. 



Gr)3 



of the iscliiuni, crosses the acetabulum at the junction of its 
posterior with its anterior two-tliirds. 

Fisr. 377. 




Sec;iou through the Hip-joi 

Gluteus maximus muscle. 12. 
Glutens medius luusclo. 

Gluteus miainius muscle. 13. 

Pyiifonuis muscle. 14. 

Great sciatic nerve and vessels. LI. 

Tendon of obturator iuternus 16. 

muscle. 17. 

Gemelli muscles. IS. 

Blcpps muscle. 13. 

Quadratus fenioris muscle. 20. 

Sartor'.us muscle. 21. 

Reflpcted tendon of the rectus 22 

muscle. -3. 
:"» :"» ^ 



nt and Gluteal region. 
, Psoas and iliacus muscles, -with 
bursa. 

Anterior crural nerve. 

Common femoral iirtery. 

Common fem)ral vein. 

Profunda artery. 

Gracilis muscle. 

Semimembranosus muscle. 

Adductor brevis muscle. 

Semiteudinosus muscle. 

Obturator exfernus muscle. 
. .Adductor longus muscle. 

Adductor magnus muscle. 



fio4 



AMPUTATIONS. 



3. The anterior border of the acetabulum is from an inch 
to an inch and a quarter to the outer side of the spine of tiie 
pubes. 

4. The axis of the horizontal ramus of the pubes, ex- 
tended by an imaginary line, crosses the acetabulum at the 
junction of its superior witli its middle third. 

5. The superior border of the trochanter major is on a level 
with the upper third of the cavity of the joint CFig. 378). 

Fix. 378. 




As the capsular ligament is attached around the borders 
of the acetabulum, it is desirable, in order to divide the 
ligament readily and open the joint, to carry the knife 
around the margin of this cavity. In doing this, it should 
be remembered that the acetabulum projects further over 
the head of the femur posteriorly than it does anteriorly, 
and the knife, therefore, when applied posteriorly, should be 
carried obliquely from behind forward and inward. 

Amputation at the hip-joint may be performed by tlie flap 
method, single or double, antero-posterior or lateral, tiie 
oval, and the circular methods. 



AMITTATION AT THE Ilir-.TOINT. 



Gr)5 



By the sin(]Ie anterior flap The patient being placed 

upon the table, with the hip projecting, the limb flexed on 
the pelvis, and separated from its fellow, the operator takes 
a position on the outside of the limb, raises the soft struc- 
tures on the anterior surface with his left hand, and enters 
the point of a long amputating knife midway between the 
anterior superior spinous process of the ilium and the great 
trochanter, and carries it to the articulation. Elevating the 
handle slightly, the point is carried over the articulation, 
transfixing the capsule as it passes, and is brought out at a 
point one inch below and in front of the tuberosity of the 
ischium, care being taken to avoid wounding the scrotum, 
which should be held out of the way by an assistant (Fig. 
379). The knife, kept in close contact with the bone, is 
carried downward, formino^ a flap six inches long, both sides 
being of equal length. The flap is now raised, and the 

artery, which it contains, 

,1 . Fig. 379. 

compressed by an assis- 
tant. AVith a large scalpel, 
the capsule of the joint is 
now divided on its ante- 
rior and inner surface, and 
the limb abducted and 
rotated outward by an 
assistant, so as to expose 
the insertion of the liga- 
mentum teres into tlie 
head of the femur. Tliis 
is divided, when the head 
of the bone can be luxated 
and the posterior portion 
of tlie capsular ligament divided. The heel of the ampu- 




656 



AMPUTATIONS. 



tating knife is now placed beliind the trochanter major, the 
point projecting as before, and the structures forming the 
posterior portion of the thigh are divided in a vertical direc- 
tion. If desirable, this last incision can be made from with- 
out inward by a circular sweep of the knife, as in the 
circular method. 

The vessels which are divided, and require ligature, are 
the femoral, obturator, sciatic, external and internal cir- 
cumflex. 

The long anterior flap is drawn downward, and united to 
the posterior by sutures. 

By the douhle-flap method Antero posterior In ampu- 
tation by this method, the anterior flap is formed in the 

same manner as in 



Fiff. 380. 




single anterior 
operation, the 



the 
flap 

lengtli being from 
three to four inches 
(Fig. 380). After 
the ligaments of the 
joint have been com- 
pletely severed, the 
amputating knife is 
placed behind the 
great trochanter, and 
tlie posterior flap, of 
the same length as 
that of the anterior, 
is made from the tissues on the back of the thigh (Figs. 
381, 382). The vessels are ligatured, and the flaps, having 
been retrenched, if necessary, are united by sutures. 



AMrUTATIOX AT THE ITIP-JOINT. 



657 



By the donhlc Jaterol flap method — The patient being 
placed on the table, with the hip projecting beyond the edge, 



Fiji. oSl. 



Fig. 382. 




a long amputating knife is entered at a point midway 
between tlie anterior superior spinous process of the ilium 
and the great trochanter, and pushed downward around the 
head of the femur on the outer side, and made to emerge 
immediately below the tuberosity of the iscliium (Fig. 383). 
The tissues over the great trochanter are drawn outward, 
and the knife is carried downward and outward around the 
great trochanter, in close contact with the bone, forming a 
flap four inches in length. The knife is reintroduced at the 
lower angle of the wound, its point carried directly upward 
around the neck of the femur, and brought out at the upper 
angle. The tissues on the inside of the thigh are now drawn 
inward, and the knife is carried dow^nward around the lesser 
trochanter, in close contact with the bone, forming a flap of 
the same length as tliat on the outside (Fig. 384). This 



658 



AMPUTATIONS. 



flap is raised, and the femoral artery grasped by an assistant. 
Disarticulation is effected by dividing the capsular ligament 
at the inner and upper part of the joint, next the ligamentum 
teres, the limb having been abducted and rotated outward in 



Fig. 383. 



Fig. 384. 




order to expose its point of insertion into the head of the 
femur, and finally completing the disarticulation by divid- 
ing the remaining portion of the capsular ligament. The 
vessels are ligatured, the flaps placed in apposition, and 
united by sutures, as before described. 

By the oval method The position of the femoral vessels 

having been definitely ascertained, the patient is placed 
upon the sound side and the point of the knife entered above 
the great trochanter and an oblique incision made back- 
ward, outward, and downward, to a point below the tuber- 
osity of the iscliium. The knife is re-entered at the upper 
angle of the wound and an incision carried forward, inward, 
and downward, terminating at a point just above the posi- 
tion of the femoral vessels. Tlie muscles on the outer side, 



AMI'LTATION AT THE HH'-JOINT. Go9 

Avliicli are attached to the great trochanter, are divided, 
exposing tlie capsule of the joint ; this is divided externally, 
and the knife, being carried to the inner side, divides the 
ligamentum teres as the limb is rotated outward. Dis- 
articulation is completed by cutting the remaining portion 
of the capsular ligament, and the knife, being placed behind 
the bone, divides tlie remaining structures by a transverse 
incision. The vessels are ligatured and the flaps approxi- 
mated by sutures so as to form a linear incision. 

By the circular method. — Amputation at the hip-joint by 
this method is performed by making a circular incision, 
dividing the skin and superficial fascia three to three and a 
half inches below the great trochanter. The skin flap is 
dissected up and a circular sweep of the knife is made, 
using great force and dividing the muscles to the joint. 
Disarticulation is effected, and the operation completed by 
ligaturing the vessels and approximating the flap in a direc- 
tion slightly oblique. 

By the modified circular method Double skin flaps and 

circular division of the muscles (Skey's operation) In 

this method of amputation the knife is entered one inch 
below the anterior superior spinous process of the ilium 
and carried down in a vertical direction for an inch and a 
half ; it is then carried inward, following nearly the line of 
Poupart's ligament and about four inches below it, and 
terminates by a gentle curve, at a point about two inches 
below the tuberosity of the ischium. The second incision 
begins at the end of the vertical incision and is carried on 
the outer side of the thigh, crossing the shaft of the femur 
immediately below the trochanter major and, passing cir- 
cularly backward, terminates at the same point as the first 
incision. The flaps being dissected up to the highest extent, 
the muscles are divided by a circular sweep of the knife, 



660 



AMPUTATIONS. 



applied witli great pressure. The joint being exposed, tlie 
ligaments are divided and disarticulation effected. The 
operation is completed by ligaturing the vessels and approxi- 
mating the skin flaps. 

By the linear and circular method — (Furneaux Jordan's 
method). — Amputation at the hip-joint by this method is 



Fig. 385. 



Fig. 386. 





Fig. 387. 




AMTUTATION AT THE IIU'-JOINT. 



GGl 



performed by makiiij; an incision on the outside of the limb 
eight inches long, beginning just above the trochanter major 
and carrying the knife to the bone. Enucleation and dis- 
articulation of the bone is now effected by dissection, the 
knife being kept in close contact with the bone. At the 
lower extremity of the linear incision, a circular cut is made 
dividing the skin and superficial fascia. This flap is dis- 
sected up for an inch and retracted, and the muscles severed 
by a circular sweep of the knife carried to the bone (Fig. 
38o). The bone is now sawn, the vessels ligatured, nerves 
retrenched, and the edges of the wound approximated by 
sutures. Figs. 386 and 387 show the stump after this 
method of operation. 

In amputations at the hip-joint or of the lower extremity 
the arterial circulation may be controlled by digital compres- 
sion of the femoral artery immediately below Poupart's liga- 
ment. It may also be controlled 
in the middle third of the thigh 
by placing a compress over the 
artery beneath the tourniquet 
and applying the pressure so as 
to compress the vessel on the 
inner side of the shaft of the 
femur. Esmarch's bandage may 
be applied, carrying the turns to 
the hip-joint, and thus control- 
ling the circulation in operations 
at any point of the extremity. 
Tiie limb may be rendered 
largely free from blood by ele- 
vation continued for some time, 
and this condition may be main- 
56 



Fis. 3SS. 




002 AMPUTATIONS. 

tained by application of the short rubber band of the 
Esmarcli apparatus. In applying the abdominal tourniquet 
(Fig. 388) the patient should be turned upon the right side 
so as to roll the intestines into that portion of the cavity 
and remove them from pressure of the pad of the instru- 
ment. The pressure of the pad may be concentrated by 
fastening a roller to it. To obtain pressure upon the aorta 
to the best advantage the pad should be placed over the 
abdomen immediately to the left of the umbilicus. The 
aorta may also be compressed by the hand introduced into 
the rectum or by the Davy's lever employed in the same 



THE UPPER EXTREMITY. 

Amputations of the Hand, — Surgical Anatomy. 
— The hand is the terminal part of the upper extremity, and 
is divided into three portions — the carpus or wrist, meta- 
carpus or palm, and the phalanges or fingers. 

Bones. — The carpus consists of eight bones arranged in 
two rows ; the first row contains the scaphoid, semilunar, 
cuneiform and pisiform ; the second row, the trapezium, 
trapezoid, os magnum, and unciform, enumerated from the 
radial to the ulnar side. 

The metacarpus is composed of five bones, and, like the 
bones of the metatarsus, are classified as long bones. 

The phalanges are fourteen in number-^two for the 
thumb and three for each finger. 

Ligaments.' — The carpal bones are attached to each other 
in the rows by dorsal, palmar, and interosseous ligaments, 
and the two rows are bound together by dorsal, palmar, 
external and internal lateral ligaments. With each other 



AMPUTATIONS OF THE HAND. 663 

an artlirodial joint is formed ; between the two rows an 
enartlirodial articulation exists. The carpus and the four 
inner metacarpal bones are connected by dorsal, palmar, 
and interosseous ligaments, while the articulation of the 
metacarpal hone of the thumb with the trapezium is enar- 
tiirodial in character, the two bones being united by a 
capsular ligament. The metacarpal bones are connected 
together by dorsal, palmar, and interosseous ligaments, and 
with the phalanges by anterior and two lateral ligaments. 

The phalanges are united by anterior and two lateral 
ligaments. The articulations between the metacarpal bones 
and the phalanges, and between the phalanges, are true gin- 
glymoid joints, and are lined by synovial membranes. 

Muscles In addition to the tendons of the flexor mus- 
cles, which are inserted into the phalanges of the thumb 
and fingers, there are three groups of muscles placed on 
the palmar surface, and connected, respectively, with the 
thumb, little finger, and the palm. 

On the dorsal surface the extensor tendons pass to their 
insertions into the bones of the thumb and fingers, while the 
interossei fill up the spaces between the metacarpal bones. 

Articulations. — The articulations of the phalanges of 
the hand with each other, and with the metacarpal bones, 
present the regular lines which are observed in the pha- 
langes of the foot. Between the metacarpal and carpal 
bones, the line of articulation is quite irregular, resembling 
in character, but in less marked degree, the irregularity of 
the line of articulation between the metatarsal and tarsal 
bones of the foot. 

In the hand the second metacarpal bone is wedged in 
between the trapezium on the radial and the os magnum 



664 



AMPUTATIONS. 



Fiff. 389. 



and base of tlie third metacarpal bone on the ulnar side, 
and the trapezoid beliind. In amputation at the carpo- 
metacarpal articulation, or in excision of the second meta- 
carpal bone, this position of the head of tlie second meta- 
carpal bone should be borne in mind. 

The line of articulation between the two rows of carpal 
bones is quite irregular, owing to the projection downward 
of the scaphoid bone, placing thus the line of junction 
between the semilunar and os magnum nearly one-half of 
an inch above. From this point the line between the 
cuneiform and unciform is ob- 
lique, terminating at a point 
nearly one-quarter of an inch 
above the point of articulation on 
the opposite side (Fig. 389). 

Bloodvessels The structures 

of the hand are supplied by the 
radial and ulnar arteries and their 
branches, wliich form arches on 
the palmar and dorsal surfaces, 
and from which interosseous and 
digital branches are given off. 
The superficial palmar arch lies 
upon the anterior annular liga- 
ment, in front of the tendons of 
the flexor muscles and the median 
and ulnar nerves, while the deep arch rests upon the carpal 
extremities of the metacarpal bones. To the thumb and 
each finger four branches are distributed, placed on the sides, 
anteriorly and posteriorly. 

Nerves. — The palmar surface of the hand and fingers is 
supplied by the median and ulnar nerves and their branches, 
the digital branches accompanying the digital arteries in 




1-5. Meta?aipal bone 

6. Ulna. 

7 Radios. 
3-15. Carpal bones. 



AMPUTATION OF TIIK FINGEKS. 



GG5 



their distribution to tlie fingers. The radial and ulnar 
nerves, with their branches, are distributed to the posterior 
surface of tl»e hand and lingers, following the course of the 
arteries. 

In amputations of the hand, it is of the utmost import- 
ance that the operation should be performed in such manner 
as to save as much of the organ as possible. Every portion 
is of value to the patient, and can be made useful by him. 
Great care and discretion should therefore be exercised by 
the surgeon when called upon to perform amputations upon 
this part. A thumb and a little finger, or a tliumb alone, or 
a little finger alone, if saved, will render better service than 
any artificial appliance which can be made. 



Amputation of the Fingers Methods At the 

phalangeal articulations or in the continuity of the bones, 
amputation may be performed by 
either the Jlap or circular methods. Fig. 390. 

At the metacarpo-phalangeal ar- 
ticulation, the oval method is best ^M 
adapted. 

In performing amputation through 
the articulations of the fingers, it is 
important to establish the relations 
to the joint of certain fixed and con- 
stant surface markings which exist 
upon the palmar and dorsal surfaces. 
Upon the palmar surface three dis- 
tinct transverse linear depressions 
are observed, which, with the finger 
in extension, have the following 
relation to the corresponding articu- 

06* 




1. Lower extremity of meta- 

carpal bone. 

2. First phalanx. 

3. Head of flr=t phalanx. 

4. Second phalanx. 

5. Third phalanx. 



(jc^a 



AMPUTATIONS. 



lations ; that at tlie commissure of the fingers is about one 
inch below the metacarpo-phalangeal articulation ; the middle 
depression, that between the first and second phalanges, is 
exactly over the joint ; and the third is about a line and a 
half beyond the articulation, between the second and third 
phalanges (Fig. 390). AVhen the finger 




is in a state of extreme flexion, the rela- 



Fiff. 392. 



tions of these depressions to the articula- 
tions change (Fig. 391). 

On the dorsal surface, the positions of 
the articulation with the finger in exten- 
sion are indicated by distinct depressions, 
which can be felt in making deep pressure 
over the joints. The line of the articula- 
tion is immediately behind the bony projections which are 
placed on the sides of the phalanges at their proximal ex- 
tremities. When the finger is an extreme flexion the distal 

extremities of the metacar- 
pal bone and phalanges 
present forward and the 
line of the articulation is 
placed below the projecting 
extremity (Fig. 392). 

Operation. — Through 
the articulation. By the 

single flap method Having 

ascertained the position of 
tiie joint, the finger is 
strongly flexed so as to 
prominently display the line 
of articulation, and a stronij 
bistoury with a narrow blade 




AMTl TATION OF THE FINOERS. 



GG7 



is made to enter the joint by a transverse incision extending 
from one side to the other (Fig. 392) ; tlie lateral ligaments 
are now divided, completely opening the joint, and the blade 
of the bistoury is introduced behind the head of the bone 
(Fig. 393) ; keeping it in close contact with the bone, it is 
carried downward, forming a palmar flap of sufficient length 
(Fig. 394). 



Fiff. 393. 



Fig. 394. 





The digital arteries may require ligature. Retrenching 
the tendons, the palmar flap is brought upward over the end 
of the phalanx and attached by suture to the dorsal flap. 

By the double flap method. — A semilunar incision is made 
across the dorsum of the finger, the points of origin and termi- 
nation being over the articulation at the sides. The flap 
is dissected up, disarticulation eflPected, and a flap of equal 
length is made from the palmar surface of the finger by 
carrying the knife downward in close contact with the 
bone. The vessels are secured, the tendons retrenched, and 
the flaps united by suture. 

By the circular method — Amputation by this method 
may be performed by making a circular incision around tiie 
finger from one-quarter to one-half of an inch below the 



668 



AMPUTATIONS. 



line of the joint. The skin is retracted and disarticulation 
effected by division of the ligaments. The vessels are liga- 
tured, tendons retrenched, and the skin flap is drawn over 
the head of the bone and tlie edges approximated in the 
transverse direction. 

Amputation in the Continuity of the Pha- 
langes. 

Operation Amputation in the continuity of the pha- 
langes may be performed by either the circular, flap, or 
rectangular flap method, the incisions being made in the 
same manner as at the articulations and the bone divided by 
the small saw or bone pliers. 

Amputation at the Metaearpo-phalangeal 
Articulation — Amputation at this articulation may be 
performed by either the oval, lateral flap, or circular 
method. 

Operation — By the oval method — Fixing the position 
of the articulation, and flexing the finger at an angle of 
forty-five degrees, the incision is 
commenced one-quarter of an 
incli above the line of the joint 
on the dorsal surface and carried 
down to the commissure. Forci- 
bly extending the finger, the in- 
cision is continued across its base 
in the fold of the skin, and thence 
upward to the point of origin. 
Dissecting up the skin and fascia, 
disarticulation is accomplished 
by dividing the extensor tendons 



Fiff. 395. 




AT THE METACARrO-rilALANGEAL ARTICULATION. GOO 

and lateral ligments, luxating tlie head of the phalanx and 
dividing finally the flexor tendons (Fig. 39o). The arteries 
should be ligatured if necessary, the tendons retrenched, and 
the flaps united by sutures. 

By the lateral flap method. — In this method the lateral 
flap is formed by carrying an incision from a point over the 
articulation obliquely downward to the side of the finger a 
short distance in front of the web, thence backward to a 
point on the under surface of the articulation. An incision 
of a similar character is made on the other side of the finger, 
uniting with the first incision at its termination. The flaps 
are dissected up and disarticulation effected as in the oval 
operation (Fig. 395). 

By the circular method. — Amputation by this method is 
performed by making a circular incision around the finger 
on a line with the fold ot" the skin on the palmar surface. 
Retracting the skin and fascia, a second incision is made, 
dividing the soft structures to the bone; these are drawn 
up and disarticulation is effected as in the other methods. 

Amputation of the Little Finger at the Me- 
tacarpo-phalangeal Articulation. — By the oval 
method. 

Opekatiox The little finger can be removed by the 

oval method, the incision being made on the side above 
the articulation in preference to the dorsal surface, as on 
tlie index finger, the incision extending upward so as to 
remove the metacarpal bone if required (Figs. 396, 397). 

Amputation of the Index Finger at the Meta- 
carpo-phalangeal Articulation By the ovalmethod. 

Operation — Amputation of the index finger at the 
metacarpo-phahingeal articulation may be performed by the 



670 



AMPUTATIONS. 



oval method, the incision beginning on the side in preference 
to the dorsal surface, thus forming a more shapely stump. 



Fior. 396. 



Fijr. 397. 





Amputation of all of the Fingers at the Meta- 
carpo-phalangeal Articulation. — By the single flap 
method. 



Fig. 398. 





AMPUTATION OF THE THUMB. 671 

Opkration The fingers, slightly flexed, are grasped by 

the operator, tlie integument firmly retracted, and a slightly 
curved incision is made from one-half to three-quarters of 
an inch below the heads of the metacarpal bones. The 
extensor tendons are now exposed and divided ; each articu- 
lation is opened and disarticulation completed by dividing 
the lateral and palmar ligaments. 
The knife is placed behind the Fig. 399. 

heads of the phalanges (Fig. 398), 
and a flap is formed by carrying it 
downward and terminating the in- 
cision at the base of the fingers 
(Fig. 399). The digital arteries 
are to be ligatured, the tendons re- 
trenched, and the palmar flap drawn over the ends of the 
bones, which may be removed by the pliers if deemed neces- 
sary, and attached by means of sutures. 

By the circular method The integument having been 

firmly retracted, a circular incision is carried around the 
base of the fingers, following the depressions in the skin at 
the commissures. The divided tissues are drawn back and 
disarticulation effected as in the flap method. 

Amputation of the Thumb at the Metacarpo- 
phalangeal Articulation. 

Operation Amputation of the thumb at the metacarpo- 
phalangeal articulation may be performed by either the flap, 
circular, or oval methods, as in the fingers. In performing 
the operation care should be taken to remove the sesamoid 
bojies connected with the metacarpal bone, and to make the 
flaps ample in order to cover the digital extremity of the 
bone, which is broad from side to side. 



672 



AMPUTATIONS. 



By the single Jlap method. 

Operation. — Amputation of the thumb at the carpo- 
metacarpal articulation by this method may be performed 
by carrying an incision from before backward through the 
middle of the commissure between the thumb and index 
finger, the former being abducted, and terminating it at 
the articulation. Disarticulation is now effected and the 
external flap is formed by introducing the knife behind and 
carrying it, in close contact with the bone, to a short dis- 
tance below the raetacarpo-phalangeal articulation. The 
radial artery may be avoided if the knife, in the first incision, 
is kept in close contact with the bone at the upper extremity. 
If divided, the artery, with the digital branches, should be 
ligatured and the edges of the flaps united by sutures. 



Fi?. 400. 



Fiff. 401, 





By the oval method — This operation may be performed 
by making an incision over the articulation between the 
trapezium and metacarpal bone, carrying it downward to 



AT THE CARrO-METACARPAL ARTICULATION. G73 

the point of junction of" the web with the tliunib, across the 
base of tiie thumb, and then back to a point at the middle 
of the first incision (Fig. 400). Keeping the knife close to 
the bone, and separating the tissues carefully, the joint is 
opened on the dorsal surface, and disarticulation completed 
by dividing the remaining ligaments. The digital arteries 
are ligatured, and the flap united so as to form a linear in- 
cision (Fig. 401). 

Amputation in the Continuity of the Meta- 
carpal Bones By the flap method. 

OPERATiOiV In performing this operation, a curved 

incision is made across the dorsum of the hand from one 
side to the other, dividing the structures to the bone. This 
flap is dissected up, and a flap is made from the palmar 
surface in the same manner, or by transfixion. The peri- 
osteum and interosseous tissues are divided, and a five- 
tailed retractor applied. The bones are sawn through, 
vessels ligatured, tendons retrenched, and the flaps united 
by sutures. 

Amputation at the Carpo-Metacarpal Articu- 
lation, leaving the Thumb By the single flap 

method. 

Operation. — The hand bx^ing in a position of supination, 
a small straight knife is enteied on the inner border of the 
hand, at the point of junction of the unciform with the fifth 
metacarpal bone, and carried obliquely across the palm so 
as to emerge at a point just below the thumb (F'ig. 402). 
The knife is now carried downward in contact w^ith the 
bones, and a large convex flap made from the palm. Plac- 
ing the hand in the prone position, a semicircular incision 
57 



67 t 



AMPUTATIONS. 



is made across the dorsum, two-thirds of an inch below the 
line of the articulation, and carried inward and downward, 
dividing the tissues connecting the thumb and index finger, 
and joining the first incision (Fig. 403). The flap being 



Fig. 402. 



Fig. 403. 




retracted, disarticulation is effected by dividing the liga- 
ments, beginning on the palmar surface. The radial and 
ulnar arteries, with, possibly, some of their branches, will 
require ligature. The tendons are retrenched, and the 
palmar flap is drawn upward and attached to the dorsal by 
suture. 



Amputation at the Wrist-joint Surgical 

Anatomy The wrist-joint unites the forearm and carpus, 

and, with the exception of rotation, possesses all of the char- 
acteristic movements of an enarthrodial articulation. 



/ 



AMrUTATIOX AT THE WRIST-JOINT. G75 

Bones The bones which enter directly into the forma- 
tion of the articnhition are the radius of the forearm, and 
the scaphoid and semilunar of the carpus (Fig. 389). The 
ulnar and cuneiform bones participate indirectly, being sepa- 
rated by the intervening articular fibro-cartilage. 

Ligaments. — The ligaments of the joint are the external 
and internal lateral, and the anterior and posterior. The 
lateral ligaments are attached above to the styloid processes 
of the radius and ulna, and below to the subjacent carpal 
bones and annular ligament. The anterior ligament, a 
broad membranous band, extends from the margins of the 
lower extremities of the bones of the forearm to the three 
carpal bones below, thus uniting all of the bones whicli enter 
into the formation of the joint. The posterior ligament, less 
thick and strong, is attached above to the radius, and below 
to the scaphoid, semilunar, and cuneiform bones. 

Muscles. — The tendons of the flexor muscles pass in 
front of the joint, and the tendons of the extensor muscles 
behind. 

Bloodvessels. — The anterior and posterior carpal branches 
of the radial and ulnar arteries, with the anterior and pos- 
terior interossei and branches from the deep palmar arch, 
supply the joint. 

Nerves. — The nervous branches which are supplied to the 
joint are derived from the ulnar. 

Line of the articulation — The line of the articulation is 
curved, owing to the convex surfaces presented by the union 
of the three carpal bones, which are received into the con- 
cave surfaces of the radius and ulna. The marked projec- 
tions formed by the styloid processes of the radius and ulna 
are guides to the position of the articulation. It is to be re- 
membered, however, that the styloid process of the radius 



G76 



AMPUTATIONS. 



Fiff. 404. 



projects downward about one-sixtli of an inch below tliat of 
the ulna. The articulation lies from a sixth to a fourth of 
an inch above a line passing through the extremities of the 
two styloid processes, the position of which is further in- 
dicated by the middle fold of skin on the palmar surface of 
the wrist. 

Amputation at tlie wrist-joint may be performed by either 
the circular or the flap method. 

Operation By the circular method. — The forearm be- 
ing held in a position midway between supination and pro- 
nation, a circular incision is made around the limb about an 

inch below the styloid pro- 
cesses, dividing the skin and 
fascia. The cuff of skin and 
fascia being dissected up and 
turned back to a point above 
the line of the articulation, 
a second circular incision is 
made, dividing the remain- 
ing structures to the joint 
(Fig. 404). Disarticulation 
is effected by carrying the 
knife on the posterior part 
along the curve of the carpal 
bont-s, th(3 hand being forcibly 
flexed. The styloid pro- 
cesses of the radius and ulna 
may be sawn off on a level with the incrusting cartilages. 
The radial, ulnar, and interosseous arteries will require liga- 
ture. The tendons of tlie flexor and extensor muscles 
should be retrenched, and the edges of the flap approxi- 
mated in the transverse direction. 




AMPUTATION AT THE WRIST-JOINT. 



G77 



By the single flap wetJiod. — Tlie lumd being held in a 
prone position, a slightly convex incision is made from one 
styloid process to the other across the back, dividing the 
structures to tlie bone. The skin is retracted and the joint 
opened on tiie dorsal surface. Disarticulation being effected, 
the amputating knife is placed behind the bones of the car- 
pus (Fig. 405), and carried downward in close contact with 
them, forming a flap of sufficient length from the anterior 
surface of the palm (Fig. 40G). The styloid processes are 



Ficr. 405. 



Fiff. 406. 





sawn off, if necessary, the vessels ligatured, tendons re- 
trenched, and the long flap drawn upward over the surface 
of the bones, and united to the posterior flap by sutures. 

By the double flap method. — The hand being slightly 
flexed, a convex incision extending from one styloid process 
to the other is made, first on the dorsal, and then on the 
palmar surface of the hand, forming tw^o flaps, each one 
inch and a half in length. These flaps are dissected up to 
the joint, disarticulation performed, and the operation com- 
pleted as in the previous methods. 

57* 



678 AMPUTATIONS. 

Amputation of the Forearm. — Surgical Ana- 
tomy. — The forearm is that part of the upper extremity 
comprised between the arm and the hand, and is composed 
of two bones, muscles, with bloodvessels, nerves, and other 
structures. 

Bones The bones of the forearm are two in number, 

the radius and ulna — the former placed on the outside and 
the latter on the inside. The ulna is the larger and longer 
of the two ; its upper extremity is thick and strong, firmly 
fixed in its position, and enters, by the olecranon process, 
largely into the formation of the elbow-joint. The lower 
extremity is small, movable, and, owing to the interposition 
of the articular fibro-cartilage, does not participate directly 
in the formation of the wrist-joint. The radius is less in 
length and size than the ulna ; its superior extremity is 
small, movable, and enters but slightly into the formation of 
the elbow-joint. The lower end is large and expanded, and 
forms the chief part of the wrist-joint. 

Ligaments The radius and ulna are united by two liga- 
ments, the oblique and the interosseous membrane. The 
former extends from the base of the coronoid process of the 
ulna, to a point on the radius just below the bicipital tuber- 
osity. The latter, beginning about an inch below the tuber- 
osity, extends between the bones to their lower extremities. 

Muscles — The muscles, which are placed on the anterior, 
radial, and posterior surfaces of the forearm, are twenty in 
number, and are classified as flexors, pronators, supinators, 
and extensors. In the upper and middle portions of the 
forearm the fleshy bellies of these muscles are placed, while 
in the lower part they terminate in tendons. 

Bloodvessels — The structures of the forearm are supplied 
by the radial, interosseous, and ulnar arteries, with their 



AMrUTATION OF THE FOREARM. 



679 



brandies, placed on the outer, middle, and inner surfaces. 
Numerous large veins ramify in the superficial fascia on the 
anterior, lateral, and posterior surfaces. 



Fis. 407. 




Section tbrouirh tbe Middle of ibe Rigbt Forearm, sbowinof structure. 



1. Anterior interosseous vessels 

and nerves. 

2. Radial vessels and nerves. 

3. Pronator radii teres muscle. 

4. Supinator longus muscle. 

5. Flexor carpi radialis muscle. 

6. Supinator brevis muscle. 

7. Flexor sublimis digitorum 

muscle. 

8. Extensor carpi radialis lougior 

and brevior muscles. 

9. Flexor carpi ulnaris muscle. 



10. Extensor ossis metacarpi pollicis 
mutc'.e. 

11. Ulnar vessels and nerve. 

12. Extensor communis digitorum 
muscle. 

13. Flexor profundu.s digitorum 
muscle. 

14. Extensor carpi uluaris muscle. 

15. Median nerve. 

16. Posterior interosseous vessels 
and nerve. 

17. Extensor secundi internodii 

poUicis muscle. 



680 



AMPUTATIONS. 



Nerves. — The median, ulnar, radial, and interosseous 
nerves, and their branches, are dis- 



Fkr. 408. 




3-1 



i-U 




-2 



tributed to the forearm (Fig. 407). 

Amputation of the forearm may 
be performed at any point in tlie 
upper, middle, or lower third. The 
rule of saving as much of the limb 
as possible should be the guide in 
operations upon this part. 

The circular, flap, or rectangular 
flap method may be employed. In 
the lower part, the circular or modi- 
fied circular method is best adapted, 
owing to the absence, to any great 
extent, of muscular structures. 

In sawing the bones of the fore- 
arm, the saw should be applied so 
as to divide the smaller and more 
movable bone first. Section of the 
bones can be facilitated by pressing 
the thumb between the bones, so as 
to maintain them in position. 

In the lower third By the cir- 
cular method. 

Operatiox The forearm being 

held in a position midway between 
pronation and supination, and the 
skin retracted, a circular incision is 
carried around the limb, dividing 
the skin and superficial fascia (Fig. 
408, 1). The cufi'of skin and f^iscia 
is dissected up, forming a flap equal 



AMPUTATION OF THE FOUKARM LOWER THIRD. G81 

in length to one-fbuitli of the circumference of the limb at 
the point of section of the bones, and, if necessary, slit up, 
in order to turn it back. The cuff being held back, a second 
circular incision is carried around the limb, dividing the 
muscular structures to the bone. The muscles, with the 
periosteum, are dissected up to a slight extent, and the inter- 
osseous membrane divided. A three- tailed retractor, the 
middle tail passing through the opening in the interosseous 
membrane, is applied, so as to thoroughly retract and pro- 
tect the soft structures, and the saw applied to the bones so 
as to divide the ulna first. The radial, ulnar, and inter- 
osseous arteries will require ligatures. The tendons should 
be retrenched, and the Hap united in a transverse direction. 

In the lower third. — By the rectangular Jlap method. — 
The forearm being held in a prone position, incisions divid- 
ing the structures to the bone are made on either side, 
beginning at the point of section of the bones and carried 
down so as to form a flap equal in length to one-half or one- 
third the circumference of the limb. These incisions are 
joined at their points of termination by a transverse incision 
across the posterior surface of the limb, and the flap is dis- 
sected up. The short flap, measuring one-fourth the length 
of the long flap, is formed by making an incision across the 
anterior surface of the limb. This flap is dissected up, the 
interosseous membrane divided, and the bones sawn through. 
The vessels are ligatured and the long flap is drawn over 
the ends of the bones and approximated to the short flap by 
sutures. 

In the lower third By the modified circular method 

This method of amputation may be employed in the lower 
third of the forearm, the skin and superficial fascia being 
divided by incisions from without inward so as to form 



682 AMPUTATIONS. 

antero-posterior flaps. These are dissected up and the 
remaining structures are divided bj a circular sweep of the 
knife. The bones are sawn through and the operation com- 
pleted as in the flap method. 

In the middle third — By the single Jiap method In this 

operation the flap is made, by transfixion, from the struc- 
tures on the anterior surface of the forearm of sufficient 
length to cover the ends of the bones. The structures on 
the posterior surface are divided by a slightly convex 
incision. The remaining steps of the operation are per- 
formed as in the circular method, and the anterior flap is 
drawn over the ends of the bones and united to the posterior 
flap by suture. 

In the middle or upper third By the double Jlap method. 

— The arm being placed midway between supination and 
pronation, the point of the amputating knife is entered close 
to the inner edge of the radius and brought out below at the 
inner edge of the ulna (Fig. 408, 2). Carrying it down- 
ward in close contact with the bones to the extent of half 
an inch, it is brought obliquely outward, forming a semi- 
circular flap. Re-entering it at the same point as before, a 
similar flap is made on the outside. The flaps being turned 
back, a circular sweep is made with the knife around the 
bones, dividing the remaining structures with the periosteum. 
The periosteum is dissected up to a slight extent, the inter- 
osseous membrane divided, and the retractor applied. 
The bones are sawn tlirough, the arteries ligatured, and the 
flaps approximated by suture. 

Amputation at the Elbow-joint. — Surgical 
Anatomy — The elbow is a true ginglymoid or hinge-joint, 
uniting the humerus with tlie radius and ulna. 



1 



AMPUTATION AT TlIK ELIJOW-.JOINT. 



683 



Fiff.409. 




1. Humerus. 

2. Oleci-auon process of uln; 

3. Head of radius. 



l^ones. — Tiie bones entering into the formation of the 
joint are tlie humerus above, and tlie radius and uhia below. 
The trochlear surface of' the hu- 
merus is received in the greater 
sigmoid cavity of the ulna, whilst 
the radial head articulates with tlie 
cup-shaped depression on the head 
of the radius (Fig. 409). 

Ligaments The ligaments of 

the joints are the anterior, posterior, 
internal, and external. Together 
they form a capsular ligament which 
completely incloses the joint. 

Mxiscles The muscles in rela- 
tion with the joint are, in front, the 
brachialis anticus ; behind, the tri- 
ceps and anconeus; internally, the common tendon of 
origin of the flexor muscles of the forearm, and flexor carpi 
ulnaris ; externally, the common tendon of origin of the 
extensors of the forearm, and the supinator brevis. 

Bloodvessels. — Branches of the brachial and anastomos- 
ing branches of the brachial with the radial and ulnar 
arteries, form a network of vessels around the joint. 

Nerves. — Branches of the ulnar and musculo-cutaneous 
nerves supply tlie joint (Fig. 410). 

Line of the articulation The line of articulation is 

irregular, being transverse between the radius and humerus 
and oblique, from without inward, between the ulna and 
humerus. The condyles of the humerus are marked 
prominences, which may be taken as guides to the joint. 
The external, which is the smaller, is a quarter of an inch, 
and the internal, larger and more prominent, three-quarters 



684 



AMPUTATIONS. 



of an inch above the line of the articulation. The position 
of the condyles, and their relations to the line of articulation, 

Fiff. 410. 



1 . Cephalic vein. 

2. Basilic vein and iuternal cuta- 
neous nerve. 

3. Musculo-spiral nerve. 

4. Median nerve. 

5. Bracliial artery and venaj com- 
ites. 

6. Anastomotica magna artery. 

7. Radial recurrent artery. 
S. Median vein. 

9. Biceps muscle. 

10. Triceps muscle. 

11. Supinator longus and extensor 
carpi radialis longior mutcles. 

12. Origin of flexor and pronator 
muscles. 

13. Capsule of joint. 

14. Extensor carpi radialis longior 
muscle. 

15. Pronator radii teres muscle. 

16. Supinator longus muscle. 

17. Tendon of the biceps muscle, 
beneath which is the brachialis 
anticus muscle. 




- 12 

- /3 



stiuclures in relation with the anterior 
aspect of the Elbow joint. 



should be always borne in mind in amputation through the 
joint (Fig. 411). 

Operation By the circular method. — The arm being 

held in the position of supination, a circular incision is car- 
ried around it three inches below the line of the articulation, 
dividing skin and superficial fascia. The cuff of skin and 
fascia is dissected up to the joint and turned back, and a 



AMri TATION AT THE ELBOW-JOINT. 



685 




second incision is made, dividing the muscles to the joint 
(Fig. 412). The ligaments are divided and disarticulation 
completed by severing 
the attachment of the 
tendon of the triceps 
muscle to the olecranon 
process, or sawing through 
the process. The bra- 
chial artery, and possibly 
some articular brandies, 
i-equire ligature. The 
edges of the flap are 
united in the transverse 
direction. 

By the single flap 
method. — The forearm 
being in a position of 
supination and slightly 
flexed, the operator, 
standing on the inner 
side of the limb, raises 
the tissues in front of the 
joint and enters the am- 
putating knife about an 
inch below the internal 
condyle (Fig. 413). 
Carrying it obliquely 
across the limb in close 
contact with the bones of 

the forearm, the point is brought out a half of an inch below 
the external condyle. Cutting downward in the direction 
in which the knife is placed, a flap three inches in length is 
58 



1. Humerus. 

2. Radius. 

3. Uloa. 

4. Exterual condyle. 
'). lateraal caudyle. 

6, 7, S. Interarticular line. 

Fig. 412. 




686 



AMPUTATIONS. 



formed. The flap being retracted firmly, a slightly curved 
incision is made on the posterior aspect extending from the 
external to the internal angle of the first incision, opening 
the joint (Fig. 414). The anterior and lateral ligaments 



Fig. 413. 



Fig. 414. 




are now divided, and the insertion of the tendon of the 
triceps muscle severed or the olecranon process sawn 
through. The arteries are ligatured and the anterior flap 
is drawn over the surface of tiie bone and secured to the 
posterior by sutures. 



Amputation of the Arm Surgical Anatomy 

The arm is that part of the upper extremity which is em- 
braced between the shoulder and elbow. It is cylindrical in 
form, flattened on the sides, and convex in front and behind. 



AMPUTATION OF THE ARM. 



G87 



Bone The bone of the arm is the humerus, the longest 

and hirgest bone of the upper extremity. 

Muscles Tlie muscles on the anterior surface of the arm 

are the coraco-brachialis, biceps and brachialis anticus. On 
the posterior surface, the triceps and subanconeus. 

Bloodvessels.— T\\Q brachial artery, passing down on the 
inner side, supplies, with its branches, the structures of tlie 
arm. 

Nerves, — The musculo-cutaneous, musculo-spiral,and in- 
ternal cutaneous are tlie principal nerves distributed to the 
arm. The median and ulnar nerves, large trunks, pass 
down on the inner side, but give off no branches to the 
arm (Fig. 415). 

Amputation of the 
arm may be performed 
at any point and by 
either the circular, 
flap, rectangular flap, 
or oval method. 



1. 


Biceps muscle. 


2. 


Cephalic vela. 


3. 


Brachial vessel--. 


4. 


Musculo cutaneous nerve 


5. 


Median neive. 


6. 


Brachialis auticus nius 




cle. 


7. 


Ulnar nerve. 


s 


Musculo-spir.il nerve. 


9. 


Basilic vein, with inter. 




nal cutaneous nerves. 


10. 


Superior profunda ves- 




sels. 


11. 


Inferior profunda ves- 




sels. 


12. 


Triceps muscle, witl 




fibrous intersection. 




Section through the Middle of the Right 
Arm, Bhowin ' structure. 



G88 



AMPUTATIONS. 



Opfration In the lower or middle third. By the 

circular method The arm being held away from the body, 

a circular incision is carried about it, dividing the skin and 
superficial fascia (Fig. 408, 3) ; the cuff of skin and fascia 
is dissected up to the extent of an inch or two inches accord- 
ing to the size of the limb, and turned back ; a second 
incision is made at the margin of the retracted flap, dividing 
all of the structures to the bone (Fig. 416). The periosteum, 
Avith the muscles, is dissected up, the retractor applied, and 
the bone sawn through. The brachial artery, with the pro- 
funda branches, will require ligature. The edges of tlie 
flc4) are united by sutures in the trans- 
verse direction. 

In the lower third. By the rectan- 
gvlar flap method — In amputation by 
tiiis method the short flap, including 

Fig 417. 



Fi?. 416. 





the biachial artery, is placed on the 
posterior surface of the arm. In 
making the longitudinal incisions, 
tlierefore, it is important to remember 
TO place the one on the inner side, 
above the line of the brachijil artery (Fig. 417). The re- 
maining steps of the operation are the same as those in that 
upon the forearm (p. 681). 



AMPUTATION AT TIIK SllOULDKK-.TOINT. 689 

Tn the upper, middle, or lower third. By the single flap 
method. — Amputation by this method may be performed at 
any point, the flap being taken from the anterior, posterior, 
or Literal surface. Tlie flap is formed by transfixion, 
being made of sufficient length to cover the end of the bone, 
while the short flap is made from without inward by carry- 
ing the knife diiectly down to the bone. The operation is 
completed as in tlie thigh (p. 646). 

Tn the upper, middle, or lower third. By the double flap 
method. — In this operation the flaps are of equal length and 
may be made from tlie anterior and posterior, or from the 
lateral surfa('e. 

Operation The arm being at right angles with the 

body, the tissues are gn.sped, elevated from the bone, and 
transfixion is made. Carrying the knife downward in close 
contact with the bone to a distance of two to two and one- 
half inches, and cutting obliquely outward, the flap is 
formed (Fig. 408, 5). Re-entering the knife at the same 
point, a second flap is made in a similar manner. The 
retractor is applied and a circular swee[) is made with the 
knife around the bone, dividing the periosteum and the 
remaining structures. The periosteum is dissected up, the 
bone sawn through, the vessels ligatured, and the flaps 
approximated by sutures. 

Amputation at the Shoulder-joint Surgical 

Anatomy The shoulder-joint is an enarthroidal or ball- 
and-socket joint, connecting the upper extremity to the 
shoulder. 

Bones. — The bones which form the shoulder-joint are 
the scapula and the humerus, the globular head of th<^. 

58* 



C90 



AMPUTATIONS. 



Fm. 418. 



humerus being received into the shallow glenoid cavity on 
the head of the scapula (Fig. 418). 

Ligame7its. — The ligaments of the shoulder-joint are the 
capsular, coraco-humeral, and glenoid. 

The capsular is a large, loose ligament which is attached 
above to tiie circiunference of the glenoid cavity, and below 

to tlie anatomical neck 
of the humerus, com- 
pletely inclosing the 
joint. The coraco-hu- 
meral is an accessory 
liorament which stren^rtli. 
ens the upper and inner 
part of tlie capsular. The 
glenoid is a fibrous band 
covering the glenoid 
cavity, which serves to 
deepen it, and is con- 
tinuous with the long 
tendon of the biceps 
muscle. 

Muscles The muscles in relation with the joint are, 

above, the supra-spinatus ; below, the long head of the 
triceps; internally, tlie subscapularis ; externally, the infra- 
spinatus and teres minor ; within, the long tendon of the 
biceps. The deltoid covers the articulation on the outer 
side, in front, and behind. 

Bloodvessels — Branches of the anterior and posterior 
circumflex and supra-scapular arteries supply tlie joint. The 
axillary is not in intimate relation with the articulation. 

Nerves — Branches of the circumflex and supra-scapular 
are distributed to the joint (Fig. 419). 




1. Head of the linmerns. 

2. Clavicle. 

'?>. Acromion proces?s. 
4. Infi-a-sp'.nous fossa. 

o. Head of humerus conned ed to i^leni.id 
cavity of .scapula bycapsiilar iiicari-ent. 



AMPUTATION AT TIIK SHOULDEU-JOINT. 



G91 



Guides to the articuhttion. — Tlie acromion process forms 
u prominent projection above the joint which can be easily 
recognized. It is phiced nearly half of an inch above the 
glenoid cavity and projects :»n inch beyond it. The cora- 



Fig. 419. 



10. 



Clavicle. 

Acromion process. 
Supra-spinatus muscle. 
Trapezius muscle. 
Intra-spinatus muscle. 
Teres miuor muscle. 
Teres major muscle. 
Latissimus dorsi muscle. 
Coraco-bracliialis and 
short head of the biceps 
muscle. 

Tendon of the subscapn- 
laris muscle, blended with 
the capsulai- ligament. 
Pectoralis major muscle. 
Deltoid rauFcle. 
Axillary vessels aud 
nerves. 




/3 9 

Section thi-ough Right Shoulder 
showing structure. 



■joint, 



eoid process is situated within and lower down, and more 
nearly in contact with the articulation. 

Amputation at the shoulder-joint may be performed by 
either the oval, single, or double flap method. 

By the oval method (Larrey's opeiation). 

Operation Elevating the shoulder of the patient and 

projecting it beyond the edge of the table, a vertical incision, 
three inches in length, beginning at the apex of the acromion 
process, is carried downward in the long axis of the arm, 
dividing the tissues to the bone. From the centre of this 
incision two oblique incisions are made, one on the anterior 
and the other on the posterior surface of the arm, extending 
respectively to the anterior and posterior borders of the ax- 



092 



AMPUTATIONS. 



ilia (Fig. 420). The flaps thus formed are dissected up so 
as to uncover the joint. The arm is now rotated outward, 
and the insertion of the subscapular muscle into the lesser 
tuberosity divided. The capsular ligament and the long 
tendon of the biceps muscle are next divided and the arm is 
rotated inward in order to separate the insertions of the 



Ym. 420. 



421. 




], 2, 3, -1. Wound after Larrey's 

operation. 
5. Glenoid cavity and remains of 

cap-ular ligament. 
Axillary vessels. 



supra-spinatus, infra-spinatus, and teres minor muscles into 
the greater tuberosity. Disarticulation is completed by di- 
viding the remaining portions of the capsular ligament, and 
the amputating knife is placed behind the bone, and the two 
oblique incisions are joined by a transverse incision, which 
divides the structures containing the axillary artery (Fig. 
421). The artery should be seized as soon as divided, and 



AMPUTATION AT THE SITOrLDER-.TOTNT. G93 

ligaturecl. The anterior and posterior circumflex arteries, 
with, possibly, otlier articular branches, will require ligature. 
The edges of the wound are approximated, so as to form, 
when union has occurred, a linear cicatrix. 

By the oval method (Spence's operation). — An incision 
three inches in length, is made on the inside of the arm, 
from a point just external to the coracoid process downward, 
passing in the line of separation between the deltoid and 
clavicular portion of the pectoralis major dividing these as 
well as the tendon of insertion of the latter muscle ; from 
the lower end of the vertical incision the knife is carried, in 
a slightly curvilinear direction, outward, dividing the fibres 
of the deltoid muscle, to the posterior border of the axilla. 
A third incision is now made, from the junction of the 
first and second, on the inner surface of the arm, dividing 
the skin and fascia only to join the incision made on the 
outer surface. The flap on the outer surface can now be 
raised, exposing the articulation ; the capsular ligament, 
with the long tendon of the biceps and the points of inser- 
tion of the supra-spinatus, infra-spinatus, and teres minor 
into the greater tuberosity and that of the subscapularis into 
the lesser tuberosity, should be divided, disarticulation ef- 
fected, and the anterior and posterior incisions joined by 
section of the tissues containing the axillary artery. The 
vessels should be ligatured in the same manner as in the 
Larrey mr^thod. The advantages claimed for this method 
of operation are a better formed stump, the division of 
smaller articular branches, and the ease with which the 
joint is exposed. 

By the single Jlap method (Dupuytren's operation). — 
In this operation the flap, which is formed from the deltoid 
muscle, may be made either by transfixion or by cutting 



694 AMPUTATIONS. 

from without inward. In the fortner, tlie knife is entered 
about an inch in front of the acromion process, carried 
directly across the joint, and brought out at the posterior 
fold of the axilla. It is then carried downward in close con- 
tact with the bone, and a broad flap of sufficient lengtli 
(three to four inches) is made. This flap is raised, and dis- 
articulation effected by dividing the ligamentous and mus- 
cular structures attached to the head of the bone by a semi- 
circular incision, the head being drawn away from the 
glenoid cavity. The knife is now passed behind the bone 
and carried to the lower margins of the first incision, and 
the intervening tissues are divided on a level with the in- 
ferior attachments of the pectoralis mnjor and latissimus 
dorsi muscles. 

In the latter, the incision is commenced near the anterior 
border of the deltoid muscle on a level with the articulation, 
descending in a curved direction to within two-thirds of an 
inch of the insertion of the muscle and, ascending on the 
posterior surface, terminates at the same level as the point of 
origin (Fig. 422). This flap is dissected up, disarticulation 
effected, and the amputating knife passed behind the bone, 
and the inferior incision made from within outward. The 
arteries are ligatured and the incisions united by sutures. 

By the double flap method (Lisfranc's operation) In 

this method the amputating knife is entered at the outer 
side of the posterior border of the axilla, in front of the 
tendons of the latissimus dorsi and teres major muscles ; 
passing obliquely upward in close contact with the joint, 
the handle is elevated and the point is brought out in front 
and below the clavicle in the triangular space formed by 
the acromion and coracoid processes and the clavicle (Fig. 
423). The arm being drawn from the body, and the deltoid 



AMPUTATION AT THE SHOULDER-JOINT. 



695 



muscle raised from the bone, the knite is carried downward 
in close contact with the bone, forming a posterior semi- 
circular flap three inches in length. Disarticulation is 
effected, and the knife passed behind the bone, and the 



Fiff. 423. 



Fig. 422, 




anterior flap, of the same length as the posterior, is made 
by carrying it downward and forward, dividing the structures 
which contain the axillary artery (Fig. 424). The arteries 
are ligatured and the flaps approximated by sutures. 

In amputation of the forearm or at the elbow the arterial 
circulation may be controlled by digital compression of the 
brachial artery in the middle of the arm, or by the appli- 



696 



AMPUTATIONS. 



cation of the tourniquet over a compress at the same part. 
Esmarch's bandage may be used as in the lower extremity. 



Fiff. 424. 




In. amputation of the arm or at the shoulder-joint, the 
subclavian artery may be compressed against the first rib 
by the handle of a key well padded. The hemorrhage may 
also be controlled by carrying the narrow band of the 
Esmarch apparatus around the axilla close to the body. 



PART VII. 
EXCISION OF BONES ANB JOINTS. 



The tprms Excision^ Exsection, iind Resection may be 
applied without distinction to operations having for their 
object the removal of the articular extremities of bones, or 
of bones in part or whole. The operation has been performed 
from an early period of time in those cases in which the 
local character of the injury or disease did not demand 
removal of the limb or part of it by amputation. 

The general adoption by surgeons of the operation in 
proper cases has without question contributed largely to the 
preservation of both life and limb. The table of statistics 
compiled by Heyfelder, of St. Petersburg, and published in 
1861, shows that in 1280 cases of excisions of bones, 932 
recovered, 266 died, and 82 failed, giving a percentage of 
deaths amounting to 36.04. Of 961 excisions of joints 684 
recovered, 186 died, 91 failed, giving a percentage of deaths 
of 36.78. The table prepared by Prof. S. W. Gross of excision 
of tlie shaft of bones for gunshot injuries in 1657 cases gives 
the percentage of deaths at 23.47. In 3596 cases of gun- 
shot injuries of the joints in which excision was performed 
the percentage of deaths, as reported by Prof. Gurlt, of 
Berlin, was 33.92. The mortality, in nearly 6000 cases of 
amputations is shown by Mr. Lane to be 3G.92 per cent. 

An examination of the tables, the results in which are 
59 



698 EXCISION OF BONES AND JOINTS. 

quoted above, shows that of the bones, the greatest mortality 
followed excision of those of the face, and of the joints, the 
hip gave the highest mortality, and the ankle, the lowest. 

The conditions which indicate the employment of excision, 
as an operative measure, may be traumatic or pathological. 

Shaft or Body of the Bones — The traumatic conditions 
occun-ing in the shaft or body of the bones are — 

Protrusion of the fragments, to such extent, in compound 
fractures as to prevent reduction, in which excision of por- 
tions of the protruding ends may be required. 

Comminution of the bone in fracture or gunshot wounds 
may require the removal of the portions comminuted and 
deprived of periosteum. 

The pathological conditions are chiefly those due to caries 
or necrosis in which excision is necessary in order to stop 
suppurative action and permit repair to occur. 

In ununited fractures excision may be practised as a method 
of treatment. It may also be performed for the relief of de- 
formity after union in fracture or where it may be desirable 
to straighten a bone in rachitis. 

Articular Extremities. — The traumatic conditions occur- 
ring in the articular extremities of bones which demand 
excision are quite numerous. 

Fractures involving the joints are frequently of such 
nature as to necessitate the removal of the fragment or frag- 
ments in relation with the joint. 

In compound dislocations it may be necessary to excise 
the displaced articular end in order to effect reduction. 

Excision of the head of the bone may be indicated in old 
unreduced dislocations in which great pain is experienced 
from pressure upon nerves. 

The chief pathological condition which demands exci- 



PROCESS OF REPAIR AFTER EXCISION. 699 

sion is chronic inflammation of tlie joints in which all of the 
structures are involved, with erosion of tlie articular surfaces 
and very great suppuration, producing severe constitutional 
disturbance. 

Excision may also be performed to relieve the great de- 
formity which sometimes attends anchylosis of a joint, or in 
certain forms of club-foot, irremediable by other means. 

' Cnntra-indications The conditions which contra-indi- 

cate the performance of excision are, extensive involvement 
of the articular surfaces, which, if removed, would leave the 
limb useless, the existence of malignant disease, the presence 
o^ acute inflammation, structural disease of the lungs or kid- 
neys, symptoms of osteo-myelitis, and rapid extension of the 
articular disease indicating a constitutional vice. In addition 
it may be stated that excision may be performed with safety to 
relieve conditions involving the articulations of the upper 
extremity, which would contra-indicate interference in the 
hip and knee-joint. The age of the patient is also to be 
considered; the tendency to recovery exists to a very marked 
extent in the young, and in these excision should not be 
resorted to at too early a period of the disease. Old age Is 
a contra-indication, owing generally to the feeble character 
of the reparative processes. 

Process of Repair after Excision After excision of the 

articular surfaces of bones, or of a portion of a bone, if the 
surfaces are kept in apposition, an immobile osseous union 
will occur as in fractures. If the cut surfaces are more 
widely separated and if motion is maintained, the ends will 
be attached by a dense fibrous band, forming a false joint. 
This condition is favorable in excisions performed upon the 
joints of the upper extremity in which it is desirable to pre- 
serve tlie prehensile function of the limb. In these joints 



700 EXCISION OF BONES AND JOINTS. 

the usefulness of the limb is preserved best when the con- 
necting fibrous band is short. In the articulations of the 
lower extremity osseous union is preferable as, with this, 
the function of the limb as a support is better accomplished. 

In the excision of an entire bone, or of a portion of a bone 
in its continuity, it is of the greatest importance that the 
periosteum should be preserved. In excisions performed 
for the relief of pathological conditions the removal of the 
periosteum may be accomplished without great difficulty, as 
it is, in these cases, thickened and the process of bone forma- 
tion has commenced in its inner osteo-genetic layer. In 
excisions performed for traumatic conditions the periosteum 
is in the normal condition, and in the adult firmly adherent 
to the bone. To remove it in such cases without laceration 
r'equires careful dissection, so that its bone-producing func- 
tion may not be destroyed. In eight cases of excision of 
the lower jaw performed by me for pliosphorus necrosis re- 
production of bone has occurred in each case to such extent 
as to furnish an excellent basis for an artificial denture. Of 
these eight excisions, one included the entire bone, one 
three-fourths of the bone, and the remaining, one-half. 

The importance of retaining a portion of the epiphysis of 
long bones in persons under twenty years of age, at which 
time the growth of the bone in length is completed and con- 
solidation occurs between the diaphysis and epiphysis, is 
very great. Removal of the entire epiphysis in a child will 
result in an arrest of growth in the length of the bone. 

In performing excisions, the following instruments are 
required : — 

Scalpel (Fig. 425) and dissecting forceps (Fig. 243), 
retractors (Fig. 246), sharp and probe-pointed bistouries 
witii strong blades and handles, bone director (Fig. 426), 



INSTRUMENTS REQUIRED FOR EXCISION. 



701 



periosteal elevators (Figs. 427, 428), shield of wood or sole 
leather to place between the bone and soft tissues during 
section of the bone, saws of different kinds — that of Mr. 



Fig. 425. 



Fi-. 426. 



Fig. 427. 



Fi-. 428. 




Butcher is especially designed for the purpose, having a 
narrow reversable blade ; the semi-circular saw of Mr. Hey, 
a small metacarpal saw (Figs. 429, 430, 431, 296), and a 
chain saw with handles or fastened to a frame (Figs. 432, 

;)9* 



'02 



EXCISION OF BONES AND JOINTS. 



433). To seize and obtain firm hold of the bone during dis- 
section a number of strong forceps with various curves will 



429. 



Fi-. 430. 



Fig. 431. 





be required (Fig. 434, 435). Cutting pliers, straight and 
curved, are also needed to cut away spicula of bone and to 
divide small bones (Figs. 297, 436, 437, 438, 439). Chisels, 
scrapers, and gouges of various forms, with a metal mallet, 
will be required to scrape away and gouge out diseased bone 



INCISIONS TO HE EMPLOYKD. 703 

(F'igs. 440, 441, 442, 443). A tourniquet may be placed 
over the main artery to control capillary bleeding during 

Fig. 432. 




the operation. An Esmarch bandage applied to the limb 
secures a bloodless field of operation. Large bloodvessels 
are not usually divided in operations of excision, as the dis- 
section of the soft tissues is generally made at points re- 
moved from their position. 

A syringe to wash out the wound should be provided. In 
performing excisions, as in other operations, proper prepa- 
rations should be made beforehand. The instruments, 
dressings, and all articles needed during the operation 
should be arranged and placed in convenient places ; the 
assistants, usually four or five, should be instructed in their 
duties. As a rule, the patient should occupy the recumbent 
position. 

The incisions made in reaching the part of bone to be 
excised vary according to the situation of the joint or bone. 
A straigiit or slightly curved incision may be employed in 
the excision of any joint or bone. The H and square in- 



704 



EXCISION OK BONES AND JOINTS. 



cisions are objectionable on account of the angles formed, 
which are difficult to approximate accurately and maintain 



Fig. 433. 



Fiff. 434. 



Fiff. 435. 





SECTION OF THE BONE. 



705 



ID proper apposition, whereby tlie process of healing is de- 
layed. AVhen it is necessary to include diseased tissue in the 



Fis:. 436. 



Fig. 437. 



Fiff. 438. 





incision the elliptical form may be employed. Care should 
be taken to avoid retrenchment of the flaps, as sufficient 
shrinking usually occurs to adapt them to the parts. 

The section of the bone is made after it has been com- 
pletely exposed by the incision and denuded of its perios- 
teum which, as stated above, is a difficult and tedious oper- 
ation in accidents and acute conditions, but much less so in 
those of a chronic character. When the chain saw is used 
tlie bone need not be lifted from its place, the cliain being 
readily slipped beneath it by an eyed probe armed with a 



706 



EXCISION OF BONES AND JOINTS. 



thread; the leather shield to protect the parts and receive the 
bone dust may also be pushed beneath the bone. If thestraiglit 



Fiff. 439. 



Fig. 440. 



Fi^. 441. 




saw is employed, the bone should be raised from the wound, 
and supported upon a soft wooden shield while section is made. 
In operations done upon the forearm and leg care should be 
taken that the bones are divided on the same level, other- 
wise the limb may be forced to one side and its functions 
greatly impaired. After section, the end of the bone and 
the medullary canal should be carefully examined to see that 
they are free from disease. In joint excisions, the line of 



SECTION OF THE IJONE. 



707 



section should always be outside of the insertion of the liga- 
ments, as experience has shown that inflammation is very 



Ficr. 442. 



Fig. 443. 




f^ 



liable to occur if any portion of the ligaments is left. In 
every instance the section should be made through healthy 
bone, otherwise a speedy return of the disease will ensue. 
If the periosteum is found detached from the surface, the 
uncovered portion of the bone should be excised, as exfoli- 
ation is liable to follow in such cases. The saw should be 
used in dividing the bone in preference to the cutting pliers, 
as this instrument produces contusion of the parts, with more 
or less irregular edges. 



708 EXCISION OF BOXES AND JOINTS. 

After removal of the bone, hemorrhage, if present, should 
be controlled by the application of pressure or by douching 
the wound with hot water ; if necessary ligatures may be 
employed. The wound should then be thoroughly cleansed 
by injections of warm antiseptic lotions and the periosteum 
carefully replaced. When all of the bone dust and spicula 
have been removed, drainage tubes should be introduced so 
as to secure complete drainage of the wound cavity and the 
edges brought together by interrupted sutures. Antiseptic 
dressings should be applied, and the limb should be band- 
aged and placed upon a splint which is so arranged as to 
permit examination and dressing of the wound without dis- 
turbance of the limb. After excisions upon the articula- 
tions of the upper extremity passive movements should con- 
stitute part of the treatment, as it is of great importance that 
movement of the joints be established. In operations upon 
those of the lower extremity this is not requisite, as osseous 
union, in proper position, is desirable in order to afford sup- 
port. The adoption of the antiseptic methods of treatment 
will to a great extent, if not entirely, prevent the occurrence 
of excessive suppuration, pyaemia, erysipelas, and septicaemia, 
which under other plans increased greatly the dangers of 
excisions. 

Morphia, by the mouth or preferably by hypodermic inr 
jection, should be given to allay the muscular spasm which 
is prone to follow the operation and disturb the process of 
repair. Should suppuration ensue, stimulants, with tonics 
and good diet should be given. Prolonged suppuration, 
with the formation of sinuses, indicates generally the recur- 
rence of disease of the bone which may be relieved by a 
second operation, providing that this will not cause the loss 
of too much bone. In this event amputation should be per^r 
formed. 



STKOIAL EXCISIONS SKULL. 709 

SPECIAL EXCISIONS SKULL. 

Cranium Surgical Anatomy — The bones of the 

head, or cranium, are so articulated as to form a cavity in 
which is lodged the brain and its membranes. Tlie articu- 
hitions are of the synarthrodia! or immovable variety, and 
bind the different bones firmly together. The external sur- 
face of the vertex and sides of the cranium are covered by 
the integument, which is thick in this portion and studded 
with hair follicles ; by the superficial fascia, a firm, dense 
membrane intimately adherent to the integument, and to the 
occipito-frontalis muscle and its aponeurosis, and by the occi- 
pito-frontalis muscle which, with its tendon, extends from 
the occiput to the eyebrow, covering one side of the entire 
vertex, the muscular portions extending from an inch and 
a half to two inches, the frontal portions being the longer. 
On the sides, the temporal muscles occupy the temporal 
fossa? covered by the strong and dense fascia which is at- 
tached to the temporal ridge. Covering the surfaces of the 
bones is the pericranium, a delicate periosteal membrane. 
The arterial supply to the scalp on the top and sides is 
furnished by the anterior and posterior temporal and occi- 
pital arteries. The nerves are derived from branches of the 
supra-orbital, temporal, auricularis magnus, and occipitalis 
major and minor. The flat bones forming the vertex consist 
of two compact layers, with the spongy or diploic tissue 
between. The external table is strong and dense, while the 
internal or the vitreous is very brittle. The diploic tissue 
contains a number of sinuses or venous channels which 
ramify in tortuous directions throughout the structure, being 
composed of the fiontal, anterior and posterior temporal, and 
occipital. The internal surface of the cranijd bones is lined 



710 EXCISION OF BONES AND JOINTS. 

by the dura mater, the fibrous membrane of the brain, whieli 
forms tlie internal periosteum. The dura mater contains 
the meningeal arteries and their branches, and the superior 
longitudinal and lateral sinuses, two large venous channels 
having important surgical relations. The superior sinus 
occupies the attached margin of the falx cerebri, beginning 
at the crista galli and passing backward, terminates at the 
internal occipital protuberance in the lateral sinuses. In its 
course, it grooves the inner surface of the frontal bone, tlie 
apposing margins of the two parietal, and the superior por- 
tion of the crucial ridge of the occipital bone. The lateral 
sinuses begin at the torcular Herophili, a slight distance to 
the side of the internal occipital protuberance, and are 
lodged in the attached margin of the tentorium cerebelli. 
As they pass to their termination in the jugular foramina, 
they rest upon the inner surface of the occipital bone, the 
posterior inferior angle of the parietal, the mastoid portion 
of the temporal, and the upper surface of the jugular process 
of the occipital. The position of these important vascular 
channels should be borne in mind in all operations upon the 
vertex and the mastoid portion of the lateral region. 

The thickness of the cranial walls differs at different points, 
being thickest at the protuberance of the occipital bone 
and thinnest in the temporal region and roofs of the orbits. 
The cranial bones of different individuals vary greatly in this 
respect. In some they are very thin, fracturing under the 
application of the slightest force. In others, especially in 
negroes, the bones are sometimes found to be very thick, 
measuring frequently one-quarter to one-half of an inch at 
all points. 

The conditions which demand excision of portions of the 
cranial walls are necrosis, morbid growths, intracranial 



THE CRANIU^I. 711 

collections of blood or pus, the removal of foreign bodies, as 
bullets or fragments of knife blades, the relief of epilepsy or 
insanity due to bone pressure, and fractures causing depres- 
sion of the bone, with symptoms of brain compression, or 
injury to the brain by rough edges or spicula of bone, 'in 
necrosis and morbid growths, the disease may be limited to 
the external plates, and relief may be afforded by removal 
of this portion of the bone alone. In operations for the 
removal of intracranial collections of blood or pus, or of 
pressure by bone, either recent or chronic, the opening into 
the cavity is made through both plates of bone by the tre- 
phine, or where a compound fracture exists the bone may be 
elevated and excised with the pliers. The question with 
regard to the employment of the trephine in cranial injuries 
is one of great importance, and its discussion has recently 
taken a wide range. 

It may be stated in general that excision of the cranial 
bones is indicated and should be performed in the adult in 
all instances of injury which are accompanied by depression 
of the bone and symptoms of compression; in compound 
fractures with symptoms of compression, with or without 
depression; it may be proper in similar cases, with depres- 
sion and without symptoms of compression ; in compound 
comminuted fractures with depression ; in punctured frac- 
tures; in compound fractures, in which inflammatory symp- 
toms develop, which may be due to spicula of bone pressing 
upon the brain. In the child, owing to the comparative 
thinness of the cranial walls and the accompanying elasticity 
by reason of which depression may occur without fracture 
and without the occurrence of marked brain pressure, the 
use of the trephine is rarely required. Under the process 
of growth and development the brain may accommodate itself 
to the altered shape of the cranial wall. In all cases, where 



12 



EXCISION OF BONES AND JOINTS. 



it is possible, the forceps and elevator, with the pliers, should 
be employed in preference to the trephine. 

The gravity of the operation does not exist in the effect 
upon the bone, but in that exerted upon the important and 
sensitive organ and structures within the cavity surrounded 
by them. Section of the external and internal plates with 
the intervening diploic structures may be regarded as an 
operation of no greater gravity than that of the compact and 
cancellated tissue of a long bone. The primary and second- 
ary effects exerted upon the brain and its membranes by the 
cranial injuries which are amenable to relief by the operation 
upon the bones, give to it an importance not possessed by 
any otlier. 



Fis;. 444. 



Ficr. 445. 




The instruments required for the performance of excision 
of the cranial bones consists of a scalpel (Fig. 242), dissect- 
ing, arteiy (Figs. 434, 435), and bone ibrceps (Fig. 435), a 
tenticulum, trephines, cylindrical and conical in shape, and 



TIIK OKANirM. 



713 



of (liri'erent diameters (Fi^ns. 444, 445, 440), a probe witli ji 
flat end, a brush to remove the bone dust from the teetli of 
the trephine (Fi^. 447), an ehivator (Fig. 448), a lenti- 
cular (Fig. 449), a Hey's saw (F'ig. 450), a Holsen chisel 
(Fig. 451), ligatures, sutures, and needles. The crucial 



Fill. 446. Ficr. 44S. Fiir. 449. 



Fiir 450. 



Ficr. 451. 






Fi-. 44: 




incision has been usually employed in the section of tlie 
scalp, but it is not as advantageous as that semilunar or 
horse-shoe shaped in form. 

Operation Tiie patient having been placed in the re- 
cumbent position with the head elevated, an anaesthetic is 
administered and tiie liair removed by the razor for some 

00* 



714 



EXCISION OF BONES AND JOINTS. 



Fig. 452. 



distance around the wound. If the patient is unconscious by 
reason of the compression exerted by depressed bone or 
other cause, the anaesthetic may be withhekl. If a wound 
of the scalp exists, it may be enlarged in the necessary 
directions, or a horse-shoe shaped incision may be made 

carrying the knife to the bone 
and reflecting the flap thus form- 
ed (Fig. 452). Bleeding from 
the divided vessels of the scalp 
may be controlled temporarily 
by the hj^mostatic forceps and 
usually permanently, without dif- 
ficulty by the sutures employed 
in closing the wound, in this 
manner dispensing with liga- 
tures. If a depression of the 
bone exists tlie trephine should 
be applied over the border of the 
depression, tlie pin of the instrument being pushed down into 
the sound bone. A circular incision of the pericranium should 
be made before application of the instrument. The trepliine 
having been fixed in position by the pin, it should be revolved 
by a movement of supination and pronation of the hand 
until a slight groove is made by the teeth, when the pin 
should be retracted and held firmly in this position by the 
screw (Fig. 445). The instrument should be re-applied and 
the section of the bone cautiously proceeded with. The bone 
dust should be removed from the teeth of the trephine by the 
brush or a wet sponge and the groove in the bone cleaned by 
the flat end of the probe. Section of the diploe will be 
indicated by the flowing of blood into the wound ; from this 
point great care should be exercised during section of the 




THE CKANIUM. 715 

tliiniier internal table. The button of the bone should be 
grasped by the forceps and gently moved in order to ascer- 
tain when it is entirely iree. It may be removed in the open- 
ing of the trephine or picked out with the forceps. After 
removal of the section of bone, the wound is gently cleansed, 
the flap replaced, and secured by silver wire sutures, sufficient 
intervals being left for the escape of the wound fluids. The 
wound should be dressed antiseptically, and the treatment of 
the patient conducted so as to avoid the occurrence of 
inflammation. 

In compound and comminuted fractures, the fragments of 
bone may be removed with the bone forceps and elevator, 
the use of the trephine being dispensed with. This plan 
should always be adopted when practicable. In a case of 
compound comminuted fracture of the frontal and parietal 
bones, under my care some years since, I removed, in this 
manner, twenty-four fragments of bone, varying in size, 
the largest fragment being the size of a silver dollar, and 
detached from the internal table. In a number of instances 
of compound and comminuted fractures of the cranium, I 
have succeeded in effecting removal of the fragments and 
elevation of the depressed bone with the forceps and eleva- 
tor. If possible to avoid it, the trephine should not be 
applied over the course of the longitudinal or lateral sinuses, 
or their point of union at the occipital protuberance ; over the 
frontal sinuses, or the anterior inferior angle of the parietal 
bone, at wdiich point the middle meningeal artery enters the 
cranial cavity. When the condition demands operation at 
these points care should be taken to avoid wounding these 
important vessels. Hemorrhage from a sinus may be con- 
trolled by pressure with a compress of lint for a few hours, 
or, if necessary, a double lateral ligature may be applied. 



716 



EXCISION OF BONES AND JOINTS. 



Fiff. 453. 



In using the trephine, the operator should avoid making 
too much pressure, lest by reason of a thin cranial wall or 
almost complete section of the bone, great injury be inflicted 
upon the brain, or its membranes by the forcible passage of 
the end of the instrument into the cranial cavity. The coni- 
cal-shaped trephine is for this reason the safer instrument to 
use. It is also important to bear in mind that, for the pur- 
pose of elevating depressed bone, a small trephine, one- 
half of an inch in diameter, is sufficient. Great care is to 
be exercised with regard to the use of the pin attached to 
the instrument, which, if not retracted and secured in place, 
may perforate the bone before section is complete. A modi- 
fication of the trephine has been devised by Dr. Hopkins, of 
this city, in which the pin rests 
upon a spring, and, as the teeth 
penetrate the bone, it is pushed up 
into the interior of the crown (Fig. 
453). 

The wounding of the dura mater 
is to be carefully avoided, as such 
a procedure greatly complicates the 
operation ; if the operation is per- 
formed to evacuate pus or blood 
lying beneatli this membrane it 
should then be incised in order to 
afford escape for the fluid. 

Eepair after excision of the cra- 
nial wall takes place by fibrous tis- 
sue, and the part must be protected 
by the adaptation, externally, of a 
metal plate. In rare instances, a thin layer of bone is re- 
produced. 




MAT.AR nOXK — TTPPF.n JAW. 717 



FACK. 



Malar Bone. — Surgical Anatomy. — Themalar bone, 
one of the double bones of the face, is situated at the upper 
and outer part of the face, and enters into the formation of 
the orbit and zygomatic and temporal fossae. It articulates 
with tlie frontal, sphenoid, and temporal bones of the cra- 
nium, and the superior maxilla of the face. Its position is 
quite superficial, and its relations, except to the sphenoidal 
fissure, are not very important. Several small arterial and 
nervous branches traverse canals in its substance. 

It may be the seat of necrosis, or participate in gunshot 
and other fractures of the bones of the face requiring exci- 
sion. It is frequently removed in part or entire in operations 
of excision of tix; upper jaw. 

The bone may be exposed by a curved incision carried 
from the external angle of the frontal bone to the maxillary 
process. 

Opekatiox. — When excision of the bone is required as 
an independent operation, it may be exposed by the incision 
given above, the periosteum reflected, and the frontal, zygo- 
matic, and maxillary processes divided with the pliers, and 
the bone grasped with the forceps and dislodged. In gun- 
shot fractures the fragments which are detached may be re- 
moved with the forceps. After excision the wound should 
be closed by suture, dressings applied and retained in posi- 
tion by roller. 

Upper Ja"W Surgical Anatomy The participa- 
tion of the upper jaw in the formation of three important 
cavities, the mouth, nose, and eye, associated with the ex- 
istence of a cavity within its interior, the maxillary sinus. 



718 EXCISION OF BONES AND JOINTS. 

renders the surgical relations of the bone of great import- 
ance in connection with the various diseases, benign and 
malignant, with which it is liable to be attacked. Its articu- 
lation with two bones of the cranium and seven of the face 
increases the importance of its surgical relations when it be- 
comes the subject of operation. It articulates by its nasal 
process with the nasal bone and frontal; by the inner margin 
of its superior or orbital surface, with the lachrymal, eth- 
moid, and palate ; by the inferior turbinated crest with the 
inferior turbinated bone ; by the palate process with the pal- 
ate, vomer and fellow of the opposite side ; and by the malar 
process with the malar bone. In its complete removal, these 
articulations are all severed, either by disruption or section 
with the saw, and the mouth is deprived of nearly one-half 
of its roof, the nose of its outer wall and a part of its floor, 
and the orbit of its floor, leaving a large cavity which exposes 
nearly the anterior half of the base of the cranium. The 
infra-orbital artery and superior maxillary nerve are divided 
in complete excision of the bone. 

The morbid conditions demanding excision of the bone 
are tumors of a recurrent or malignant form involving the 
entire structure, originating either in the antrum or in the 
substance of the bone. 

Fibroid tumors, which are frequently limited in their 
growth to the external surface of the bone, can be readily 
removed from the surface, and therefore do not demand dis- 
articulation of the bone. Sometimes they produce, by pres- 
sure, absorption of the osseous tissue, and force their way 
into the cavities of the antrum, nose, or orbit, requiring in 
such cases excision of a greater part of the bone. 

Enchondromata^ originating either from the external sur- 
face or the interior of the antrum, likewise cause absor{)tion 



TIIK UPPER JAW. 719 

by pressure and involve in their removal the greater portions 
of the bone. 

Osseous tumors existing in their simplest form, as an hy- 
pertrophy of the whole or a part of the jaw, or as the result 
of the transformation of pre-existing growths, compels the 
excision of those parts involved. 

Sarcomatous tumors require extirpation of the entire jaw, 
or free excision in those of the less malignant character. 

Carcinoma of the jaw, of whatever form, demands the re- 
moval of the entire bone. A difference of opinion exists 
with regard to the propriety of operative interference in car- 
cinomatous affections of the upper jaw. The difficulty, in 
advanced cases, of obtaining complete removal of the dis- 
eased tissue and the speedy recurrence of the growth in the 
majority of cases after operation, suggest grave doubts as to 
the benefits to be derived from an operation, in itself, of a 
serious character. In the early stages, the growth may 
occupy an area so circumscribed as to permit of its entire 
removal, the patient gaining, if not complete relief, at least 
an immunity of longer duration than when the disease is 
attacked after its full development. Secondary operations 
should not be performed, as it is impossible to reach, after 
recurrence, the limits of the disease. 

Operation — The patient should be placed in the semi- 
recumbent position upon a firm table and an anaesthetic ad- 
ministered. The instruments required for the operation are 
scalpel, dissecting forceps, cutting pliers of various angles 
(Figs. 297, 437), strong forceps, among them the lion-jawed 
forceps (Figs. 454, 455), the metacarpal, Hey's or Adams's 
saw (Fig. 456), chisels, gouges, and retractors. Sponge- 
holders should be provided, in order that sponges may be 
carried into the mouth and pharynx to remove the blood 
and prevent its passage into the larynx. 



720 



EXCISION OP BONES AND JOINTS. 



Lines of Incision Incisions in various directions have 

been employed for the purpose of exposing the upper jaw at 
the time of removal. The chief object in the selection of any 
line of incision is to obtain sufficient exposure of the parts 



Fis. 454. 



Fiff. 455. 



Fio-. 456. 





in order to avoid embarrassment to the operator during the 
ditferent steps of the operation. A consideration of some 
importance is to avoid division of the facial artery and nerve 
at such points as to give rise to Iree hemorrliage at the time 



THE UPPER JAW. 



721 



Fk. 45: 



of the operation, and subsequently to extended paralysis ol* 
the muscles of the face. It is a matter of some importance 
also to avoid section of the duct of the parotid gland (Steno's 
duct), which, if made, may result in the formation of a sali- 
vary fistula. The incision, at first employed, began at the 
ancrle of the mouth, and was carried in a curved direction 
across the cheek, to the malar bone or external angle of the fron- 
tal bone (Fig. 4o7, 1). To this 
incision has been added another, 
which is carried tVom the point of 
termination of the first beneath 
the inferior border of the orbit to 
the side of the nose. By these 
incisions large branches of the 
facial artery and nerve are divi- 
ded. In order to avoid section of 
these large branches, Sir William 
Fergusson suggested and employ- 
ed a line of incision, wLich began ^-" 
at the middle of the upper lip, and 

was carried to the column^e nasi and round the ala of the 
nose to the inner angle of the eye and from this point beneath 
the inferior border of the orbit to external angle of the 
frontal bone (Fig. 457, 2). This incision divides the artery 
and nerve where their branches are smallest and the flap 
formed is extensive enough to uncover the entire surface 
of the jaw. The only objection to be offered to this line 
is the formation of angles, the edges of which are difficult to 
approximate accurately and in the union of which the repara- 
tive process is slow. To overcome this objection I have 
employed a curved incision which begins near the angle of 
the mouth, passes along the ala of the nose to near the inner 
61 




722 



EXCISION OF BONES AND JOINTS. 



angle of the eye, and then curves out to the external angle 
of the frontal bone (Fig. 458). 

Operation — Having raade the incision the operation 
is continued by rapidly dissecting the flap from the sur- 
face and entrusting it to the care of an assistant who grasps 
the bleeding points and compresses them by the fingers, 
meanwhile making pressure on the facial artery as it 
passes over the border of the lower jaw in front of the 
anterior inferior angle of the masse- 
ter muscle. The portion of the 
flap attached to the nasal process is 
now to be detached, and, if neces- 
sary, the points of attachment of 
the cartilage of the nose to the 
nasal spine. As the hard palate is 
divided alongside of the line of 
articulation of the two bones the 
detachment of the nasal cartilage 
may be omitted. The middle in- 
cisor tooth of the side operated upon 
is now extracted, and an incision is made from the alveolus 
backward to the posterior border of the horizontal portion of 
the palate bone, dividing the tissues on the roof of the 
mouth, and the soft palate is then detached from the palatine 
border. The nasal process is now divided by the cutting 
pliers or metacarpal saw, the section being made obliquely 
upward so as to terminate at the lower border of the lachry- 
mal groove. The articulation between the malar process of 
the jaw and the malar bone is likewise divided by the pliers 
or saw, and the separation of the bones from each other is 
accomplished by section of the hard palate with the meta- 
carpal saw, the blade being entered into the cavity of the 




THE UrPER JAAV. 



723 



no»e for that purpose (Fig. 459). The bone is now seized 
with the lion-jawed forceps (Fig. 454), forcibly depressed 
and abducted and adducted so as to separate the suture be- 
tween the pterygoid process of the sphenoid bone and palate 
bone, and also the articulations within the orbit, the tissues 
occupying the floor of the orbit having been detached with 
care and pushed up with the handle of the knife. As soon as 
the bone is removed sponges, which have been prepared anti- 
septically, should be pressed into the wound with some force 

Fig. 459. 




in order to check the bleeding, which is usually controlled 
by this means. If this is not sufficient, hot water may be 
employed to stop the general oozing, and animal or carbo- 
lized silk ligatures should be applied to the arteries requiring 
them. The hemorrhage having ceased, the cavity should 
be cleansed and packed with 77-^ per cent, iodoform gauze and 
the fla[)S re{)laced and sutured with silver wire, the incision in 



724 



EXCISION OF BONKS AND JOINTS. 



the lip being secured by a harelip pin and carbolized silk 
ligature, and the line of incision covered with iodoform gauze 
and retained in place by adhesive strips or a bandage. 
Union takes place very promptly between the edges of the 
incision, and the sutures may be removed in part or in whole 
on the fourth day. The cavity left by the removal of the 
jaw is partially closed by a formation of fibrous tissue ; 
where the operation has been performed for the removal of 
malignant growths, the return of the disease in the part is to 
be expected sooner or later. In non-malignant affections, 
limited to the anterior surface or to the alveolar process, par- 
tial excisions of the upper jaw may be performed without ex- 
ternal incision of the over- 
■^^S" "^^^^ ly^"o tissues or with those 

of limited extent, from the 
lip to the ala of tlie nose 
or beyond to the inner 
angle of the eye (Fig. 
460). More or less diffi- 
culty attends the attempt 
to remove, through the 
mouth, morbid growths in- 
volving the u[)per jaw,and 
the surgeon is unable to 
obtain such view of the 
parts as to be confident of 
tiie entire extirpation of 
tlie disease. In cases of 
necrosis, in wliicli detach- 
ment of the dead bone has 
occurred, its removal can be readily accomplished through 
the mouth without external incision. In many instances the 
orbital plate of the upper jaw is not involved, and may be 




THE UPPER JAW. 



725 



allowed to remain in position by malting a section of the 
bone with the saw, just beneath the lower border of the orbit. 

The application of ligatures is rarely needed in this opera- 
tion, providing care has been exercised to make the incisions 
bevond the limits of the morbid m-owths involving the bone. 
Tiie larger arterial branches of the deeper parts are suffi- 
ciently removed from the seat of operation to escape injury, 
except in an unusual involvement of the parts in the morbid 
growth. Tiie preliminary application of a ligature to the 
common carotid artery can scarcely be required in any case. 

The prognosis in excisions of the superior maxilla is ex- 
ceedingly favorable. Heyfelder's tables give 26 deaths in 
112 complete excisions, 36 in 187 partial excisions, and 5 in 
12 excisions of both bones. Prof. S. D. Gross performed 
the operation upwards of twenty times without a single loss. 
Of eight excisions performed by the author, one, a case of 
large medullary carcinoma, terminated fatally two weeks 
after the operation, x^o difficulty in controlling the liemor- 



Fio:. 461. 



Fiff. 4(52. 





rhage occurred in any of the cases, and in but one w^as it 
necessary to apply any ligatures. Figs. 461, 462 show the 
appearance presented in a sarcoma of the upper jaw of the 

61* 



726 EXCISION OF BONES AND JOINTS. 

spindle-celled variety in a girl eleven years old, and the re- 
sult subsequent to the operation of excision of the entire jaw. 

Lo"wer Javr Surgical Anatomy. — The lower jaw 

is the largest bone of the face, and consists of a body or cen- 
tral portion, two rami and two processes, the coronoid and 
condyloid, t.he latter, forming with the glenoid fossa of the 
temporal bone, the temporo-maxillary articulation. A 
number of muscles, fourteen in all, are attached to it at 
various points and are concerned in its elevation and de- 
pression, as well as in the movements of the tongue, lower 
lip, and pharynx. The inferior dental artery and nerve 
occupy the inferior dental canal within its interior, and the 
facial artery crosses its lower border at the anterior inferior 
angle of the masseter muscle. The parotid gland has an 
important relation to the ramus, the outer surface and pos- 
terior border of which it covers. The submaxillary and 
sublingual glands are placed in fossoe on its inner surface. 

Excision, partial and complete, of the lower jaw is re- 
quired for morbid conditions similar to those attacking the 
upper jaw. Tumors, occupying the external surface of the 
bone and limited in their attachment to the external plate, 
may be removed by dissection and elevation of the growth 
with the external plate. In cases of necrosis and other 
conditions, where the periosteum is not involved in tlie dis- 
ease, it should be detached and allowed to remain. 

Operation — The patient may be seated in a suitable 
chair with a rest for the head, or be placed upon the table 
in a semi-recumbent position and an anaesthetic should be 
given. The line of incision which exposes the jaw to the 
best advantage, and conceals the cicatrix formed, should 
begin slightly in front of the lobe of the ear and be con- 
tinned over the ansle to the base and along the base to tlie 



TFIE LO\VER JAW. 



727 



sympliysis ami thence upward to tlie border of the lip or 
tlirouixh the entire lip. In excision of the entire jaw the 
incision should be carried to the lobe of the ear of the oppo- 
site side. In partial excisions but a portion of the incision 
is required. In necrosis, and affections limited to the alveolar 
border, excision can be performed through the mouth and 
without external incision. The incision along the base 
will necessitate division of the facial artery, which may be 
secured, before section, by a hairlip pin introduced beneath 
the vessel and a ligature applied over it in the manner of 
the twisted suture. The bone having been exposed by the 
dissection of the overlying tissues with the masseter muscle, 
it should be divided by the chain saw, which should be car- 
ried beneath it by a threaded needle at such point as is 
required. The muscles attached to the inner surface of the 
base and angle, with the periosteum, if deemed advisable, 
should be detached with a probe-pointed bistoury or with 
the periosteal elevator, care being taken in excision of the 
entire jaw to secure the fr^ennm of the tongue with n Hiatiire 
before separation from the bone, in order to prevent its re- 
traction, which might 
result in closure of the 
glottis and suffocation 
(Fig. 463).. Separa- 
tion of the temporal 
muscle, from the coro- 
noid process and of 
the condyloid process 
from the glenoid fossa 
at the point of articula- 
tion is one of tlie most 
difficult steps of the ope- 
ration. The intimate 



Fi^. 463. 




728 



EXCISION OF BONES AND JOINTS. 



relation of the internal maxillary artery to the condyle, pass- 
ing, as it does, on the innersideoftheneck of this process, ren- 
ders it liable to injury unless the knife is used with great cau- 
tion. Although the vessel is further removed from thecoronoid 
process, lying to the inner side and behind, it may be wounded 
in the unguarded use of the knife. For the purpose of division 
of the tendon of the temporal muscle and capsular ligaments 
of the joint, the probe-pointed bistoury — that used in hernia 
is preferable — should be applied, cutting the tendon from 
without inward and the ligament upon the outer side alone. 
This partial section is usually sufficient to permit the bone 
to be detached by seizing the body and forcibly twisting it 
outward. In excision of the lower jaw through the mouth 
the tissues lying in front of the anterior border of the ramus 



Fij?. 464. 



Fis. 465. 



may be cautiously divided with the probe-pointed bistoury, 
the incision being made upward until the base of the coro- 
noid process is reached, and then section of the tendon and 



THE LOWER JAW. 



729 



ligaments may be made, if necessary, by carrying the knife 
across on the outside of the bone. Tiie hite Prof. Gross 
etFected, with great ease and safety, the separation of these 
parts by an elevator which combined the principles of 
a knife and lever (Figs. 4G4, 4G5). The blunt edge of 
this instrument is insinuated beneath the soft structures, 
peeling them off, and the processes are detached by priz- 
ing them out of place. The same precautions should be 
taken in excision of the lower jaw as in the upper with re- 
gard to a careful dissection of the structures so as to effect 
entire removal ; the avoidance of incisions into the morbid 
growtli, in order to prevent hemorrhage, and the preservation 
of the periosteum wherever it can be done with safety. The 
preservation of the periosteum is very important in opera- 
tions upon the lower jaw, as new bone formation occurs when 
tliis membrane is not removed, which provides a suitable 
basis for an artificial denture. Especially is this to be ob- 



Fio:. 466. 



Fiff. 467. 





served in operations for necrosis of the bone in which the 
new bone is readily reproduced. In a number of instances 
of excision of the lower jaw, partial and complete, performed 
by tlie author for necrosis, the reproduction of bone has been 



730 



EXCISION OF BONES AND JOINTS. 

Fig. 468. 




STERNUM AND ENSIFOKM CARTILAGE. 731 

^o complete as to prevent deformity by preserving the shape 
of the jaw and supplying a firm support for artificial appli- 
ances. This is seen in Figs. 466 and 467, representing 
the conditions in a case of phosphorus necrosis in which 
one-half of the lower jaw was excised. 

In operations upon both the upper and lower jaws Bon- 
will's surgical engine, with properly adapted burrs and saws, 
may be employed with advantage (Fig. 468). 

TRUNK. 

Sternum and Ensiform Cartilage. — Surgical 
Anatomy. — The sternum, with the costal cartilages, forms 
a portion of the anterior wall of the thorax. It consists of 
delicate cancellated tissue covered by a compact layer in 
front and behind. A number of muscles are attached to it, 
chiefly by aponeurotic points of origin. Its anterior surface 
is subcutaneous, being covered by the skin, fasci?e, and 
aponeurosis of the two pectoralis major muscles. Its pos- 
terior surface has an important relation with the anterior 
mediastinum, forming its anterior wall, with the pleurse on 
the sides and the pericardium behind. In this space, the 
internal mammary vessels of the left side are placed with a 
quantity of loose areolar tissue, in w^hich inflammation, 
leading to suppuration and the formation of post-sternal 
abscesses, sometimes occurs. In operations upon the sternum, 
the proximity of the pericardium should be borne in mind, 
and care should be exercised in the use of cutting instru- 
ments upon the posterior surface. 

The conditions requiring excision, which are, as a rule, 
partial in character, are caries and necrosis, abscess in the 
anterior mediastinum, gunshot injuries, with lodgement of 



732 EXCISION OF BONES AND JOINTS. 

foreign bodies in the substance of the bone or in the medias- 
tinum. In rare instances, where harmful pressure is 
exerted by the displaced fragment or portion in fractures or 
dislocations excision may be necessary. In extensive 
comminution of the bone by shot wounds, the pericardium 
may be exposed on removal of the fragments. It is always 
desirable to make the operations subperiosteal as far as 
possible, in order that a support may be afforded by new 
bone formation. 

Operation A longitudinal line of incision is usually 

sufficient to expose the bone for any operation. A crucial 
or semilunar may be employed, if deemed advisable. The 
diseased bone may be removed by the gouge, cutting pliers, 
Hey's saw, or the trephine. A drainage tube should be 
introduced, especially if the wound is large, and antiseptic 
dressings applied. It is very important to afford an easy 
outlet to the wound fluids lest they should dissect up the 
tissues posteriorly and enter the mediastinal space. 

Rib and Costal Cartilages Surgical Anatomy. 

— The ribs, twelve in number on each side, form the chief 
part of the walls of the thoracic cavity. From the second 
to the twelfth they are placed obliquely, the costal extremity 
being lower than the vertebral. The spaces between them 
are filled up by the intercostal muscles. In structure the 
ribs consist of cancellated tissue covered by a thin external 
compact layer. They have important relations with the 
pleura, being separated from it on the inner surface by a 
delicate areolar tissue. On the outside they are covered by 
the integument, fasciae, and muscular layers. The inter- 
costal vessels lie in a groove on the inferior border. 

Tlie conditions which may require excision of the ribs and 



RIBS AND COSTAL CARTILAGES. 733 

their cartilages are caries, necrosis, comminuted fractures, 
collections of pus in the pleural cavity, and morbid growths. 
A number of ribs may sometimes be involved, requiring 
operation. It is seldom that the entire bone demands 
removal. 

Line of incision. — In cases of caries and necrosis the 
incision may be made in the long axis of the rib following 
its curve. Where more than one rib is involved a semi- 
lunar or crucial incision may be required to expose the bones. 
For the removal of tumors connected with the ribs an 
elliptical incision should be made. When resection is per- 
formed to evacuate pus from the pleural cavity, a straiglit or 
semilunar incision will fully expose the part. 

Operation The patient should be placed in the recum- 
bent position, turned slightly upon the sound side, and an ana3S- 
thetic should be administered. When the operation is per- 
formed for caries or necrosis, the incision should be made 
directly to the bone, dividing the periosteum, which, in these 
cases, is much thickened by inflammation. This membrane 
should be separated from the bone by the elevator, which 
should be kept in close contact with the bone to avoid wound- 
ing the pleura or intercostal vessels, and the caries removed by 
chisel or gouge, or in case of necrosis, the rib divided either by 
the chain saw, which may be passed around it, by the meta- 
carpal saw, a shield being passed beneath it to protect the 
adjacent tissues, or with the pliers. After section, the rib 
should be lifted from its position, drawn out, the periosteum 
detached from its posterior surface, and the bone again di- 
vided by the saw or pliers. 

In excision of the ribs for morbid orrowths o;reat care 
should be exercised in separating the posterior attachments, 
which are, as a rule, intimately adherent to the pleura, and 
02 



734 EXCISION OF BONES AND JOINTS. 

perforation of which may occur. Hemorrhage from the 
intercostal arteries may require application of the ligature, 
carried around the rib, if necessary. 

Drainage having been provided for, the wound should be 
closed by suture, dressings applied and retained in place by 
adhesive strips or broad bandages carried around the chest. 

Pelvic Bones. — Surgical Anatomy The pelvis is 

that portion of the trunk interposed between the lower 
extremity of the vertebral column, to which it affords sup- 
port, and the lower extremities, upon which it rests. It is 
formed of four bones, the two ossa innominata, the sacrum, 
and the coccyx. Externally it is covered by the integu- 
ment, fascise, and layers of thick muscles which are attached 
to its surface, borders, and prominences ; within it is lined 
by fascia and partially by muscles and the peritoneum. 

The conditions which demand excision of the pelvic bones 
are necrosis, morbid growths, compound comminuted frac- 
tures and, in the coccyx, a condition of neuralgia following, in 
some cases, fracture or dislocation of the bone. 

The li7ie of incision may be straight or curved according 
to the position of the growth or dead bone. If sinuses 
exists these may be enlarged in any direction and the bone 
extracted through the opening. 

Operation — The patient should be placed upon the side 
or in the semi-prone position and the incision made, in cases 
of necrosis, directly to the bone, dividing the periosteum, 
which should then be separated by the elevator. Tumors 
occupying the surface of the bone may be exposed by an 
elliptical incision and the growth removed by the chisel or 
gouge. In compound comminuted fractures, the fragments 



uprEU extre:\iity — sitoulpek. 735 

which have no periostea,! attachment may be removed 
through the external wound. 

Coccyx Coccygectomy, excision of the coccyx, may 

be required in cases of coccygodynia, or painful neuralgic 
affection of the coccyx, and in necrosis. The bone may be 
exposed by an incision carried in the middle line from the 
sacro-coccv"real junction two inches downward toward the 
anus. The periosteum should be carefully detached with the 
periosteotome or elevator, the index finger of the left hand 
being kept meanwhile in the rectum to guard against wound- 
ing the bowel. It will be found frequently quite difficult 
to effect separation of the bone without breaking it up into 
small fragments, and in this way accomplishing extraction. 
In two of the three excisions of this bone which I have per- 
formed, I experienced this difficulty ; in the remaining opera- 
tion, for necrosis, the bone was easily lifted from its position. 
A drainai]re tube should be introduced extendino^ the entire 
length of the wound and emerging at the upper and lower 
angle, in order to secure perfect drainage and douching of 
the cavity. The wound, as in excisions of other portions of 
the pelvis, should be closed by suture and the dressings 
retained by adhesive strips or a broad bandage. 

UPPER EXTREMITY SHOULDER. 

Clavicle Surgical Anatomy The clavicle is 

placed between the sternum and scapula, articulating by its 
inner extremity with the manubrium of the sternum and car- 
tilage of the first rib, and by its outer end with the acromion 
process of the scapula. It receives the attachments of the 
sterno-cleido-mastoid, sterno-hyoid, pectoralis major, sub- 
clavius, trapezius, and deltoid muscles. It lias most import- 



736 EXCISION OF BONES AND JOINTS. 

ant surgical relations, by the posterior surface of its inner 
two-thirds, with large arterial and venous trunks, nerves, and 
the right lymphatic and thoracic ducts. Posterior to the 
sterno-clavicular articulation on the right side, the bifurca- 
tion of the innominate artery into the common carotid and 
subclavian occurs, with the junction of the internal jugular 
and subclavian veins, which, with numerous smaller arteries 
and veins, form a vascular network which greatly complicate 
any operations in this region. On the left side, the common 
carotid and subclavian arteries, with the internal jugular and 
subclavian veins and smaller arteries and veins, give to this 
region also important surgical relations. The anterior sur- 
face of the bone is nearly subcutaneous in its entire extent, 
being covered in addition by the platysma muscle only. 

The conditions which demand excision of the bone are 
caries, necrosis, pathological displacements of the articular 
extremities, and morbid growths. 

The incision necessary to effect excision may be made in 
the long axis of the bone, which will permit it to be exposed 
sufficiently for opei-ation in cases of caries, necrosis, or ex- 
cision of either of the articular extremities. When the bone 
is the seat of a morbid growtii, an elliptical incision may be 
employed. 

Operation The patient should be placed in the recum- 
bent position, with the shoulder of the affected side elevated 
and drawn outward. In caries or necrosis, an incision 
should be made over the anterior border, dividing the tissues 
to the bone. These with the periosteum should be separated 
with the elevator, and in caries, the diseased bone scraped or 
gouged out with the chisel. In partial excision for necrosis 
the bone can be divided with the chain saw, metacarpal saw, 
or pliers, and the dead portion removed (Fig. 4G9j. When 



CLAVICLE. 



737 



tlie entire bone is to be removeil, disartieuljition should be 
eflected at the acromio-chivicidar junction, the coraco-chivi- 
cuhir ligaments severed, the bone lifted from its position, and 
the posterior attachments carefully separated, until the sterno- 

Fls. 469. 




clavicular articulation is reached. The ligaments of this 
articulation should be carefully divided with a probe-pointed 
bistoury and the bone released. The hemorrliage which fol- 
lows the removal of the bone is usually slight, and may be 
easily controlled by pressure and douching with hot water. 

Excision of the clavicle for morbid growths' is frequently 
a very serious operation, owing to the intimate relations 
assumed by the growths to the structures lying posterior to 
the bone. A very careful dissection is necessary to avoid 
inflictino- injury upon the subclavian vein, lymphatic or 
thoracic duct, and possibly the phrenic nerve. Great care 
should be taken to prevent the entrance of air into the large 

G2* 



738 EXCISION OF BONES AND JOINTS. 

veins which may be divided ; a double ligature should be ap- 
plied before section or compression made by hcemostatic for- 
ceps. All appliances for checking and controlling hemorrhage 
should be at hand, and the handle, in preference to the blade, 
of the knife should be employed in separating the growth 
from its attachments. After removal of the bone, drainage 
should be provided for, the wound closed by interrupted 
sutures, antiseptic dressings applied and retained in position 
by the Velpeau bandage. 

In removal of the bone for necrosis, reproduction takes 
place, the entire bone having been reproduced in instances 
reported. Where excision is performed for morbid growths, 
this does not occur. The functions of the arm are very little 
if any impaired after removal of the bone. 

Scapula Surgical Anatomy — The scapula occu- 
pies the posterior and lateral aspects of the thorax between 
the first and eighth ribs, and is held in position by muscles 
which attach it to the vertebral column and occipital bone, 
as well as to tlie walls of the tiiorax, the clavicle, and 
humerus. These muscles are attached to its anterior and 
posterior surfaces, its borders, the spine, and both pro- 
cesses. It articulates by the acromion process witli the 
chivicle, and by its head witli the humerus. 

The vascular supply to the bone is derived from the supra- 
scapular artery, which crosses the supra-scapular ligament 
and is distributed to the supra-spinous fossa and acromial 
process — the posterior scapular, a branch of the transversalis 
colli, distributed to the posterior border of the bone and the 
subscapular, which supplies the subscapular fossa and sends 
off a branch, the dorsalis scapulae, to the infra-spinous fossa. 

Excision of a portion, or of the entire scapula, may be 



SCAPULA. 739 

required for caries, necrosis, gunshot wounds, and morbid 
growths. The hitter, very frequently of a malignant char- 
acter, involve the entire bone, assuming collossal proportions, 
and demanding, in some instances, for their extirpation, re- 
moval of the entire upper extremity. 

The lines of incision vary according to the character and 
extent of the operation. In excision of the acromion pro- 
cess or spine for caries or necrosis, a straight incision over 
the part will suffice to expose it and permit of its removal. 
When the entire bone is necrosed, a subperiosteal operation 
may be performed, the bone being exposed by two incisions, 
one extending the whole length of the posterior border and 
the other along the spine, beginning at the acromion process 
and terminating at the base, where it joins the posterior in- 
cision. In the removal of the bone, when the seat of large 
morbid growths, a f" -slipped incision may be employed, tlie 
horizontal portion extending along the upper border of the 
growth, the vertical crossing it and terminating at the 
lower border. 

Operation The patient, placed in the recumbent posi- 
tion, is turned upon the sound side and the body inclined 
forward. In cases of caries or necrosis involving the spine 
with the acromion process, the parts can be exposed by an 
incision carried from the acromio-clavicular junction backward 
over the spine to its base. The skin, fasciae, and points of 
attachment of the trapezius and deltoid muscles with the 
periosteum should be carefully separated from the surface of 
the bone, and the gouge or chisel employed to remove the 
caries. If the spine is necrosed and the acromio-clavicular 
articulation is intact, the ligaments of the joint wdth the 
coraco-acromial should be severed and the d^ad portion re- 
moved, or if the acromial end of the clavicle is implicated, 



740 EXCISION OF BONES AND JOINTS. 

it should be released by dissection and divided with the 
pliers or saw. When the entire bone is involved in necrosis 
subperiosteal resection should be performed by making two 
incisions as above described — one along the posterior border 
and another over the spine from the acromion process to the 
base, joining the first. These flaps should be reflected, and 
the overlying tissues and periosteum raised at this point 
with the elevator from the supra- and infra-spinous fosste, 
and then the posterior border from the superior to the infe- 
rior angle, released. The bone should now be gently raised, 
and the subscapular muscle wath the periosteum detached 
from the subscapular fossa freeing at the same time the supe- 
rior and inferior borders. The bone should now be drawn 
upward and outward, and, if the disease permits it, the neck 
divided with the pliers leaving the glenoid fossa and coracoid 
process — otherwise, the ligaments of the shoulder-joint should 
be divided as well as the structures attached to the coracoid 
process, and the entire bone removed. If the bone has been 
allowed to remain until completely detached by the necrotic 
action, the muscular attachments can be removed with the 
periosteum. 

When the scapula is the seat of a large morbid growth, 
the T-shaped incision should be employed to expose the 
tumor, from the surface of which the tissues should be care- 
fully dissected. If the integument is involved in the growth, 
an elliptical incision, over the surface or about the base of the 
tumor, directed obliquely from the point of the shoulder to the 
vertebral column, should be made. As the mass is carefully 
dissected from its position the various muscular attachments 
should be divided as they are reached. If the disease does 
not extend beyond the neck of the bone, this with the acro- 
mio-clavicular articulation should be severed. When the 



SCAPULA. 741 

outer end of tlie clavicle and the shoulder- joint are involved, 
the incision should be carried over the clavicle and in front 
and behind the shoulder-joint to the anterior and posterior 
borders of the axilla, the bone divided at a point beyond the 
disease and the arm removed with the growth. In perform- 
ing this operation, the greatest caution should be exercised 
when the region of the shoulder-joint is approached, and it 
becomes necessary to sever the vessels of the axilla in re- 
moving the arm. The dissection should be made from below 
upward, the tumor be turned up toward the neck and the 
axillary artery, if possible, isolated and surrounded with a 
ligature. The arteries distributed to the scapula should be 
ligatured as they are divided, or compressed with the haemos- 
tatic forceps until completion of the operation. In this ope- 
ration, as in that n^)on the clavicle, precaution should be taken 
against the entrance of air into the divided veins. 

Hemorrhaore having been controlled, drainaoje tubes should 
be inserted, if necessary, the wound closed by interrupted 
sutures, and antiseptic dressings applied and confined in 
position by a broad roller or spica bandage of the shoulder. 
The arm should be supported at a right angle in a sling. 

After removal of the scapula the functions of the arm are 
not very greatly impaired. Of the various movements that 
of abduction is alone destroyed. 

The mortality following total excision of the scapula is 
very slight, and the operation is found to be attended with 
less mortality than that for partial removal. Excision per- 
formed for malignant growths gives a large mortality and, 
as a rule, the operation should not be performed. Prof. 
Gross quotes the report of Prof. Adelraann in which the re- 
sults in 261 excisions of the scapula are given, 66 of which 
were total and 195 partial. Of the total excisions, 22 were 



742 EXCISION OF BONES AND JOINTS. 

traumatic, with a mortality of 27.2 per cent., and 43 patha- 
logical with a death-rate of 19 per cent., the lesion in one 
being unknown. Of the 195 partial operations, 153 were 
traumatic, with a mortality of 26.3 per cent, and 19.5 per 
cent, in those performed for disease. 

Humerus. — Shoulder-joint Surgical Anat- 
omy The shoulder-joint is formed by the reception of the 

head of the humerus into the glenoid fossa on the head of 
the scapula. The capsular ligament, re-inforced by the 
coraco-humeral, incloses the joint through which passes the 
long tendon of the biceps muscle from its point of origin, 
the upper border of the glenoid fossa, covered by a reflec- 
tion of the synovial membrane. The deltoid muscle sur- 
rounds the joint in the greater part of its extent, covering it 
on the outer side, in front and behind. Behind, the supra- and 
infra-spinati, with the teres minor muscles, are in intimate 
relation with the joint as they pass to their points of inser- 
tion into the greater tuberosity of the humerus. In front and 
to the inside, the sub-scapularis, the coraco-humeral, and 
short head of the biceps are in close relation with the joint. 
The axillary artery and vein, with the nerves of the brachial 
plexus, pass obliquely along the outer boundary of the axil- 
lary space. The anterior and posterior circumflex arteries, 
given off from the third portion of the axillary artery, 
curve backward and are distributed to the deltoid muscle, 
the neck and head of the humerus, and the shoulder- 
joint. The anterior artery gives off a branch which ascends 
in the bicipital groove to the joint, whilst the posterior winds 
around the neck of the humerus and by its branches anas- 
tomoses with the supra-scapular, acromial thoracic, and 
anterior circumflex arteries. The upper and lower branches 



lIUMKItUS — SHOULDER-JOINT. 7-13 

of the circiiindex nerve, one of the divisions of the posterior 
cord of the brachial plexus, follow, in general, the distribu- 
tion of the arterial branches to the joint. 

Tlie conditions for which excision of the shoulder-joint is 
performed are caries and necrosis, gunshot injuries, com- 
pound comminuted fractures, old unreduced dislocations in 
which severe pain is produced by pressure upon the axil- 
lary nerves, removal of the head of the bone in intra-cap- 
sular fracture when necrosis and suppuration have occurred, 
benign tumors involving the head of the humerus, and chronic 
rheumatic arthritis. In the majority of instances it is found 
that the disease is limited to the head of the humerus re- 
quiring excision of this part alone ; in shot injuries, the head 
of the scapula, with the coracoid and acromion processes'and 
the outer end of the clavicle, may be implicated and demand 
removal. 

The incisions which have been employed for exposing 
the joint are various, embracing the straight or longitudinal, 
curvilinear, U'' H^? T"? L"?^^^^ V'^^^^P^^* Of the different 
forms, that which inflicts the least injury upon the deltoid 
muscle and overlying tissues and affords, at the same time, 
ample exposure of the joint, is the longitudinal, beginning 
just beneath the extremity of the acromion process and car- 
ried downward in a straight line to near the point of inser- 
tion of the deltoid muscle, measuring some five inches in 
length. 

Operation — The patient should be placed in the recum- 
bent position with the shoulder projecting beyond the edge 
of the table. The knife should be entered below the 
acromion process, the point being carried to the bone and 
tlie incision made five inches in length dividing tlie fibres 
of the deltoid muscle. Tiie tissues being separated from the 



744 



EXCISION OF BONES AND JOINTS. 



Fig. 470. 




bone to a slight extent with the handle of the knife or ele- 
vator, should be held apart by the retractors and the arm 
rotated inward so as to permit division of the insertion of the 

supra- and infra-spi- 
nati and teres minor 
muscles into the great- 
er tuberosity, and then 
rotated outward in 
order that the inser- 
tion of the subscapu- 
laris muscle into the 
lesser tuberosity may 
be severed. The 
long tendon of the 
biceps muscles should 
now be carefully dissected from its position in the bicipital 
groove and beneath the capsule of the joint, and held out of 
the way. If not destroyed by disease, the capsule 
should now be divided and the head of the bone forced 
through the opening, the arm being carried forward. The 
leather or wooden shield being placed beneath the projected 
bone, the saw is applied and care is taken to make the sec- 
tion beyond the line of the disease (Fig. 470). The bone 
may be divided with the chain saw, and disarticulation then 
effected of the diseased portion (Fig. 471). If the glenoid 
fossa, clavicle, coracoid, or acromion processes are involved, 
the incision may be extended and the diseased portions 
removed by the pliers or chain saw. Disease of the glenoid 
fossa may be removed by the chisel or gouge after excision 
of the head of the humerus. 

Subperiosteal resection may be performed by opening the 
capsule, after the preliminary incision, and with the elevator 



HUMERUS — SHOULDER-JOINT. 



745 



detaching the insertions of the muscles into the greater and 
lesser tuberosities with the periosteum, lifting the tendon 
of the biceps from the groove, projecting the bone through 
the opening in the tissues and dividing it with the saw. 




Tlie divided branches of the circumflex arteries should be 
ligatured if required, the wound thoroughly cleansed by 
douching with a warm antiseptic lotion, a drainage tube intro- 
duced so as to traverse the entire length of the wound (Fig. 
472), the ends appearing at the upper and lower angles, and 
the edges approximated with sutures. Antiseptic dressings 
should be applied and retained by loose turns of the spica 
bandage of the slioulder, a pad placed in tlie axilla and the 
arm supported in a sling or by the third bandage of Desault, 
the object being to carry the upper extremity upward and 
bring it in near apposition with the glenoid fossa. 

The amount of bone to be excised varies in accordance 
G3 



46 



EXCISION OF BONES AND JOINTS. 



FiV. 472. 




Avitli tlie nature of the disease, it being desirable in all 
instances to make the section beyond its limits. Experi- 
ence has shown that from four to five, and, 
in exceptional instances, seven to eight, 
inches may be removed and the func- 
tions of the arm very little, if any, im- 
paired as a result. Amputation is, as a 
rule, to be resorted to in preference, 
where one-half or more of the bone 
demands removal, as the arm is found 
to be useless when excision is performed 
in these cases. In necrosis, however, 
this rule does not apply, as the bone 
reproduction is sufficient usually to pre- 
vent great impairment of function. 

Repair after Excision — Six to eight 
weeks are required to accomplish heal- 
ing, and from three to four months before the reparative 
process has advanced sufficiently to permit use of the arm. 
In cases in which the periosteum has been retained bone 
reproduction occurs, and the functions of the arm are pre- 
served to a great extent. Where this has not been done the 
movements of the arm liave not, in some instances, been 
greatly impaired. 

The mortality rate after excision of the shoulder-joint for 
all causes is very sliglit. The tables of Dr. Gurlt give the 
rate at 34.70 per cent, for gunshot injuries ; the cases 
analyzed by Dr. S. W. Gross, for similar injuries, 33.51 per 
cent ; those of Dr. Hodges 23 per cent, in primary 
operations and 38 per cent, in secondary operations. Excis- 
ion for disease in 50 cases yields a rate of 16 per cent. The 
tables of Dr. Culbertson show that the greatest mortality 



HUMERUS — SHAFT. 747 

attends tlie opertition wlien pei-fornied during the inter- 
mediary ov period of traumatic or inflammatory fever, reach- 
ing, in these instances, as high as 50 per cent. 

The mortality rate after excision of this joint exceeds that 
after amputation, the average in the former being 30 per 
cent., according to the tables of Culbertson, and 28.5 per 
cent, in the latter, according to the tables in the Surgeon- 
General's Report prepared by Dr. Otis. 

Humerus — Shaft. — Surgical Anatomy — The shaft 
of tiie humerus is that part included between the upper and 
lower extremities, cylindrical in the upper half and flattened 
and prismatic below. The musculo-spiral groove traverses 
the centre of the extei-nal border and passes across tlie 
external and posterior surfaces obliquely forward and down- 
ward. 

Below the surgical neck of tlie humerus the shaft is 
covered on the outer side and behind by the deltoid and 
triceps, and on the front and inner side by the coraco- 
humeral, biceps, triceps, and brachialis anticus muscles. 

On the inner side of the arm above, between the coraco- 
humeral, biceps, and triceps, and below, between the biceps, 
brachiali anticus, and triceps muscles, the brachial artery, 
with the median nerve, pass. The ulnar nerve diverges from 
the median in its course, leaving the brachial artery at the 
middle of the arm, and from this point it descends to the 
groove between the internal condyle and olecranon process, 
resting upon the posterior surface of the former at the elbow. 
The superior profunda artery and musculo-spiral nerve 
occupy the musculo-spiral groove and descend on the outer 
side of the arm, between the brachialis anticus and supinator 
longus muscles, to the front of the external condyle. 



748 EXCISION OF BONES AND JOINTS. 

Excision of the shaft of the humerus may be required for 
necrosis, gunshot wounds, and ununited fracture. In gunshot 
fractures, the experience in military campaigns has shown that 
more favorable results follow removal of the detached frag- 
ments alone than when the more formal operation of excision 
of the ends of the upper and lower fragments is performed. 
Favorable results have followed excision in cases of pseud- 
arthrosis, especially when performed under antiseptic me- 
thods. When performed for necrosis of the shaft, excision 
gives the most favorable results. 

The incision employed in removing the shaft should be 
made on the outer side of the arm, beginning above, in the 
interspace between the biceps, deltoid, and triceps, and ter- 
minating below between the biceps and brachialis anticus, 
following in the entire incision the external border of the 
biceps. Care should be taken, in the lower part of the inci- 
sion, to avoid carrying the knife between the brachialis anti- 
cus and supinator longus muscles, where the bifurcation of 
the musculo-spiral nerve into the radial and posterior inter- 
osseous occurs, and which may be wounded. 

Operation The patient being in the recumbent posi- 
tion, and the arm supported by assistants or placed upon 
firm pillows, the incision should be made along the external 
border of the biceps muscle as indicated above, and the knife 
carried to the bone dividing the periosteum. This membrane 
should be carefully elevated, reflected, and tlie diseased bone 
divided with the chain saw, if necessary, and removed. In 
gunshot fractures, the detached fragments should alone be 
removed, those which are partially free being allowed to 
remain with the hope that they may become consolidated. 
In ununited fractures, the ends of tlie fragments should be 



HUMERUS, RADIUS, AND ULNA ELBOW-JOINT. 749 

excised to a sliirht extent and, after adjustment, sutured by 
wire, if necessary. 

After excision, the hemorrhage, which is usually slight, 
should be controlled by torsion or ligature, the wound 
douched with a warm antiseptic solution, the periosteum re- 
placed, and the edges of the incision approximated by suture. 
A drainage tube having been introduced, antiseptic dressings 
should be applied, and the arm placed upon an internal angu- 
lar splint, secured in position by a roller and supported in a 
sling. 

Very favorable results have followed excision of the hu- 
merus for necrosis, the entire bone having been removed in 
a number of instances with success. In a few cases the 
humerus, with the upper portions of the ulna and radius, 
has been successfully excised. In one remarkable case by 
Prof. V. Langenbeck, the humerus, radius, and ulna were re- 
moved at different intervals and a serviceable limb obtained. 

The retention of the periosteum, in these cases, is followed 
by bone reproduction to such an extent as to replace the origi- 
nal structure. Tiie mortality rate following excision in 
gunshot fracture is more favorable than amputation for the 
same condition. 

Humerus, Radius, and Ulna — Elbow-joint 

Surgical Anatomy. — Tlie elbow-joint is formed by the 
lower extremity of the humerus, and upper extremities of 
the radius and ulna, and is surrounded by the triceps muscle 
behind, brachialis amicus, and tendon of the biceps in front, 
common origin of the flexor and extensor muscles of the 
forearm on the inner and outer surfaces. In front, in the 
bend of the elbow, the brachial artery with its veins, the 
radial and ulna arteries, and the median and musculo-spiral 

G3* 



750 EXCISION OF BONES AND JOINTS. 

nerves are placed. These structures are separated from the 
joint by the brachialis anticus, and su[)inator brevis muscles, 
upon which they rest. The ulnar nerve lies upon the pos- 
terior surface of the internal condyle. The vascular supply 
of the joint is derived from the superior profunda, inferior 
profunda, and anastomatica magna of the brachial, with the 
radial recurrent and anterior and posterior ulnar recurrent 
arteries. 

Excision of the elbow-joint may be demanded for com- 
pound comminuted fractures, compound and complicated 
dislocations, caries, necrosis, and gunshot injuries. 

Various incisions have been employed to expose the articu- 
lation, as the H- ^^^ X-sli^P^d incision. That which 
interferes least with the fibres of the triceps muscle and ex- 
poses the parts fully, is the longitudinal, wOiich should extend 
four inches over the posterior surface of the joint. The 
position of the ulnar nerve upon the back of the inner con- 
dyle is to be borne in mind in the section of the structures 
to expose the joint. 

Operation. — The body of the patient should be inclined 
toward tlie sound side and the affected arm supported upon 
firm pillows. The incision shoutd be made over the poster- 
ior surface of the joint to the extent of four inches as above 
described, cutting through the fibres of the triceps muscle 
and its tendon. The tissues, with the periosteum and apon- 
eurosis of the triceps upon the outer portion of tlie incision, 
should be raised with the elevator and held by a retractor 
over the external condyle. Tiie tissues upon the inner side 
should likewise be raised and placed over the internal condyle, 
great care being exercised in exposing and lifting the ulnar 
nerveoutof its position in thegroove upon the posterior surface 
of the inner condyle. It is covered bya dense fibrous envelope. 



HUMERUS, RADIUS, AND ULNA— ELBOW-JOINT. 751 



which should be carefully opened with the grooved director 
and the nerve held out of the way by a blunt hook. The parts 
being exposed, the olecranon process should be divided with 
the pliers and the lateral ligaments severed with the probe- 
pointed bistoury. The arm should now be flexed and an 
effort made to project the bones through the wound, this 
movement being facilitated by 
detaching the soft structures ^^^' ' * 

carefully with the elevator 
(Fig. 473). The shield being 
placed beneath the projecting 
ends, they should be divided 
by the saw, that portion only 
removed which is injured, or 
in a state of disease. It is de- 
sirable always, when possible, 
to limit the section to the ar- 
ticulating surfaces; the coro- 
noid process of tlie ulna, at the 
base of which tlie brachialis 
anticus is attached, and the 
tubercle of the radius into 
which the biceps muscle is in- 
serted should be preserved, 

retaining by this procedure the important function of flexion. 
Hemorrhage having been controlled, the wound should be 
thorouglily washed out, a drainage-tube introduced, the 
edges approximated by suture, antiseptic dressings applied, 
and the limb placed either upon an internal angular splint, 
in a tin or felt trough or a plaster bandage with a metal 
bracket (Fig. 92), or with an opening arranged so that dress- 
ings may be applied without disturbing the limb. Comfort 




752 EXCISION OF BONES AND JOINTS. 

may be afforded by suspending the limb in the splint, or the 
apparatus of Mr. Heath may be employed (Fig. 474). 

Some difference of opinion has existed among surgeons 
with regard to the relative dangers of complete and partial 

Fig. 474. 




excisions of the elbow-joint, the belief having been enter- 
tained that the latter were attended with more risk than the 
former and should not be practised. Experience has shown 
that partial excisions may be performed with safety in dis- 
ease, whereas in gunshot injuries and traumatic conditions 
of recent origin complete excision should be employed. 

As it is desirable to maintain movement in the joint, the 
ends of the bones should be kept separated in order to pre- 
vent bony anchylosis and that a fibrous band of union may 
form. It is also desirable that the fibrous band shall be as 
sliort as possible in order to give increased power to the 
arm. 

The tables prepared by different authors show tliat excision 
of the elbow-joint gives the most favorable results, varying 
from 10.87 to 23.05 per cent.; those for shot injuries, 19 to 
23 per cent.; for other injuries, 15 per cent. ; for disease, 10 
to 12 per cent. In gunsliot wounds, primary operations are 
much more favorable than secondary. 

Radius and Ulna — Shalt — Surgical Anatomy. 
— The anterior and posterior surfaces of the forearm are cov- 



T?ADIITS AND ULNA SHAFT. 



7r)3 



ered by the pronators, flexor, and extensor muscles, and the 
radial region by the supinator longus and extensors of the 
thumb. The radial and ulnar arteries pass along the outer 
and inner borders of the forearm, in a line from the bend of 
the elbow to the styloid processes. The interosseae arteries 
run upon the anterior and posterior surface of the interos- 
soeus membrane. The radial, median, and ulnar nerves lie 
upon the outer, middle, and inner portions of the anterior 
surface. 

Excision of the shafts of the radius and ulna may be re- 
quired for necrosis, gunshot fracture, ununited fracture, and 
morbid growths. 

The bones may be easily exposed by longitudinal incisions, 
care being taken to avoid injury to the bloodvessels and 



Fig. 475. 



Fig. 476. 





nerves of the part. An incision on the posterior surface of 
the forearm, along the border of the supinator longus muscle, 
will reach the radius without interfering witli any important 
structures (Fig. 475). To expose the ulna the incision 



754 EXCISION OF BONES AND JOINTS. 

should be made on the ulnar side of the forearm between the 
flexor and extensor carpi ulnaris muscles (Fig. 476). 

Operation The incisions having been made as above 

described, the periosteum should be carefully detached and 
the entire, or a portion of the bone removed as may be re- 
quired. In caries, the diseased bone may be removed by 
the chisel or scraper. When but a portion of the bone is 
to be excised it can be divided by the pliers or chain-saw. 
The hemorrhage will, as a rule, be slight, and can be readily 
controlled by torsion or ligature. Drainage should be pro- 
vided for, the periosteum replaced, the edges brought to- 
gether by sutures, antiseptic dressings applied, and the arm 
placed upon an internal angular splint. 

In excision of the bones of the forearm for necrosis repro- 
duction of bone occurs to such extent as to afford a useful 
limb. The repair is not as complete in partial excisions, 
nor in that of one bone, as in the operation for the removal 
of the entire bone, and both bones. The results are not, as 
a rule, very favorable in primary operations for gunshot 
fractures nor for pseudarthrosis. 

In a number of excisions for gunshot injuries, consecutive 
amputation has been demanded. The tables of Dr. S. W. 
Gross give very favorable results in partial excisions prac- 
tised for gunshot injuries, the mortality rate being 12.19 
per cent. Excision of both bones gave a larger ratio of mor- 
tality than that of the individual bones. 

Carpus Wrist-joint Surgical Anatomy The 

wrist-joint is formed by the lower extremity of the radius 
and inter-articular fibro-cartilage above, with the scaphoid, 
semilunar, and cuneiform bones below. The tendons of the 
flexor and extensor muscles of the thumb, carpus, and fingers 



CARPUS — WRIST JOIXT. 755 

are placed upon tlie anterior and posterior surfaces of tlie 
joint. The radial and ulnar arteries cross the articulation 
in passing into the hand to form the superficial and deep 
palmar arches, the former winding backward around the 
outer side of the carpus and the latter passing in front to 
the radial side of the pisiform bone. The posterior carpal 
branch of the radial, with the anterior and posterior carpal 
branches of the ulnar, are distributed to the articulation. 
The articular branches of the ulnar in front, and posterior 
interosseous nerves behind, supply the joint. The intimate 
relations to the articulation of the various tendons which 
pass in front and behind, render excision of the joint very 
difficult. The position of these structures is to be borne in 
mind in order to avoid inflicting injury upon them. 

Excision of the wrist-joint is required in cases of arthritis, 
necrosis, and gunshot injury. Owing to the peculiar form- 
ation of the articulation, disease and injury are usually not 
limited to the bones entering into the formation of the joint 
proper, but invade the ulna and inter-articular cartilages, as 
well as all of the carpal bones, and even sometimes attack 
the bases of the metacarpal bones. 

Various incisions have been employed to expose tlie joint 
as the H? L? quadrilateral, and linear incision upon the 
borders of the articulation. The objection to those which 
are carried across the surface is the division of the tendons 
in such a manner as to interfere with their future functions. 
The linear incisions should be made on the radial and ulnar 
borders, the former beginning an inch and a half above the 
styloid process of the radius and terminating half an inch 
beyond the base of the metacarpal bone of the thumb, care 
being taken to avoid wounding the radial artery as it passes 
beneath the extensor tendons of the thumb. The incision 



756 EXCISION OF BONES AND JOINTS. 

on the ulnar border should begin just above the styloid pro- 
cess of the ulna and extend downward to a point half an inch 
below the base of the metacarpal bone of the little finger. 

Operation. — The patient having been placed under the 
influence of an anaesthetic and the forearm and hand supported, 
the incisions above described should be made on the radial 
and ulnar borders of the joint. The tissues on the posterior 
surface, including the tendons, should be carefully detached 
from the radius and bones of the carpus, and the radial 
artery lifted from its position and held out of the way by a 
blunt hook. The tissues on the anterior surface of the joint 
should be detached, a straight sharp-pointed bistoury being 
passed from the ulnar to the radial side in close contact with 
the bones and carried downward until it strikes the pisiform 
bone which should be separated from its articulation with 
the cuneiform. The detachment of the pisiform bone per- 
mits the insertion of tlie tendon of the flexor carpi ulnaris 
into the base of the fifth metacarpal bone to remain undis- 
turbed. The lateral ligaments should now be divided and 
the ends of the radius and ulna projected through the 
wounds on the radial and ulnar sides, and removed on 
the same level by the chain saw or pliers. The carpus can 
now be forced through tlie wound, and the dorsal ligaments, 
uniting the two rows of bones, divided with the probe- 
pointed bistoury and separatc^d with the pliers, removing the 
upper row entirely or separately with the bone forceps. In 
the same manner the second row may be detached from the 
metacarpal bones and with them, if necessary, the bases of 
these bones. 

In this operation, the position of the radial and ulnar 
arteries and the deep palmar arch should be remembered. 

In the operation known as Mr. Lister's, two incisions are 



C A KITS. 757 

made, and it is peiTormt'd in the following manner, as quoted 
by Prof. Ashluiist. The radial incision begins about the 
middle of the dorsal aspect of the radius, on a level with the 
styloid process, and passes downward and outward toward 
the inner side of the metacarpo-phalangeal articulation of 
the thumb, but, on reaching the line of the radial border of 
the metacarpal bone of the index finger, diverges at an 
obtuse angle and passes downward longitudinally for half 
the length of that bone. An ulnar incision begins two 
inches above the end of the ulna and immediately in front 
of that bone, passes downward between the flexor carpi 
ulnaris and the ulna, and terminates at the middle of the 
palmar aspect of the fifth metacarpal bone. The only 
tendons necessarily divided by this method are the extensors 
of the wrist. The trapezium is to be separated from the 
rest of the carpus by cutting with the bone forceps before 
the ulnar incision is made, but is not to be removed till a 
later stage of the operation ; similarly, the pisiform bone is 
to be separated and leff attached to the flexor carpi ulnaris, 
while the hook of the unciform bone is also severed and left 
attached to the annular ligament. The tendons being then 
raised before and behind the wrist, the anterior ligaments 
of the joint may be divided and the cutting pliers intro- 
duced first between the carpus and raJius, and afterward 
between the carpus and metacarpus. Its connections being 
thus divided, the whole carpus except the trapezium and 
pisiform may be pulled out with a pair of strong forceps. 
The articulating extremities of the radius and ulna can now 
be made to protrude through the ulnar incision and can be 
retrenched as much as may be thought desirable, the ulna 
being sawn obliquely so as to retain the styloid process and 
thus lessen the tendency to subsequent displacement. The 
6i 



758 



EXCISION OB' BONES AND JOINTS. 



articulating ends of the metacarpal bones are then protruded 
and excised, and the operation completed by dissecting out 





the trapezium, and by removing the articulating surf{\ce of the 
thumb, and as much of the pisiform and hook-like process of 



CARPUS. 



759 



the unciform as may be found necessary. When the opera- 
tion is completed a drainage tube should be passed through 
tlie wound, the incisions sutured, antiseptic dressings applied, 
and the forearm and hand placed upon a Bond's splint with 
the sides removed, or an anterior palmar splint with a block 
of wood upon it for tlie hand to grasp, and, if necessary, 
extension may be maintained by weights and pulley. A 
plaster bandage with an iron frame for support (Figs. 477, 
47<s), or an internal angular splint may also be employed 

Fig. 479. 




(Fig. 479). Passive motion of the thumb and fingers must 
be made to prevent adhesions of the tendons whereby great 
impairment of function might result. 

The great difficulties w-hich attend excision of the wrist- 
joint and the complicated structure of the articulation, 
render the results frequently unfavorable as to the usefulness 
of the hand. The mortality rate for all conditions is nearly 
30 per cent. The expectant plan of treatment in shot 
wounds gives a rate of 7.6 ; amputation through the fore- 
arm 9.6 per cent. 



7G0 EXCISION OF BONES AND JOINTS. 

Carpus, Metacarpus, and Phalanges — Surgical 
Anatomy — The anterior and posterior surfaces of the car- 
pus are covered by the flexor and extensor tendons of the 
muscles of the carpus and Angers ; the palmar surface of the 
hand is occupied by the muscles proper of the thumb, little 
finger and the lumbricales and interossei ; on the dorsal sur- 
face the extensor tendons of the carpus, the fingers and dor- 
sal interossei muscles are placed. The arterial and nerve 
supply to the carpus has been described in connection with 
the operations upon the wrist-joint. The metacarpus and 
phalanges are supplied in front by branches from the deep 
and superficial palmar arches and behind by branches from 
the posterior carpal arch. On the palmar surface the digital 
arteries at first are placed superficial to the flexor tendons ; 
as they pass forward to the clefts of the fingers, accompanied 
by the digital nerves, they lie between them. On the sides 
of the fingers the digital arteries lie beneath the digital 
nerves. The branches from the posterior carpal arch and 
radial artery pass forward on the dorsum to the thumb and 
fingers, running in connection with tlie extensor tendons. 
The median and ulnar nerves supply the palm and send 
branches to the fingers in connection with the arteries. The 
radial and ulnar nerves supply the dorsal surface of the meta- 
carpus and phalanges. 

Excision of the bones of the carpus, metacarpus, and pha- 
langes may be required in cases of compound comminuted 
fractures resulting from gunshot or other injury, and necrosis. 

The bones of the carpus, metacarpus, and phalanges may 
be exposed and removed by a longitudinal or curved incision, 
the former being preferable. The incision should be made 
in the line of the tendons upon the dorsal surface and be- 
tween them and the arteries (Fig. 480). 



CARPUS, METACARPUS, AND PHALANGES. 



7GI 



Operation. — In cases 
of necrosis, accompanied 
by sinuses, the openings 
may be enlarged, the peri- 
osteum detached, and the 
dead bone removed with 
the forceps or by chisel 
and gouge. In shot frac- 
tures the detaclied frag- 
ments alone should be re- 
moved. In all instances 
the periosteum should be 
preserved and replaced, 
with the view to secure 
reproduction of bone. 
After operation the wound 
should be cleansed, drain- 
age by horse-hair or cat- 
gut threads secured, anti- 
septic dressings applied, 
and the forearm and hand 
placed upon a splint with 
a block for the palmar sur- 
face of the hand to rest 
upon. 

In excision of the meta- 
carpal bone of the thumb 
the iucision should be 
straight and made at the 
line of junction of the pal- 
mar and dorsal surfaces 
(Fig. 481). 



Ficr. 480. 




Fiff. 481. 




=64 



762 EXCISION OF BOXES AND JOINTS. 

In some instances very good results follow excision of the 
bones of the carpus, metacarpus, and phalanges, especially in 
those in which the expectant plan has been pursued and tlie 
dead bone detached by suppurative action. Reproduction 
of bone occurs usually in these cases and supplies a fair sub- 
stitute for the original bone. Excision should not be per- 
formed upon the first and second phalanges, as the finger 
after repair has taken place is useless and a source of annoy- 
ance. In disease or injury of the third phalanx, the opera- 
tion is eminently proper. In all operations upon the hand 
its important functions should be remembered and conserva- 
tive surgery, whenever it is possible, employed. 

LOWER EXTREMITY. 

Femur Hip-joint Surgical Anatomy The 

hip-joint is formed by the acetabulum and head of the femur, 
and is surrounded by muscles, the larger number of those 
having relations with the joint being inserted into the 
greater and lesser trochanters. Branches of the obturator, 
sciatic, internal, circumflex, and gluteal arteries are distri- 
buted to the joint, while the femoral artery and vein lie in 
front of it separated from the capsule by the psoas and pec- 
tineus muscles where their edges approximate. The joint 
is supplied by the branches of the sacral plexus, great sciatic, 
obturator and accessory obturator nerves. The anterior crural 
nerve lies in front, to the outside of the femoral vessels, and 
the great sciatic nerve lies behind the joint and between the 
trochanter major and tuberosity of the ischium. 

The conditions which require excision of the joint are 
gunshot injuries and caries and necrosis developed in con- 
nection witli coxal^ia. 



LOWER KXTREMITY — IIIP-.TOINT. 7G3 

Various incisions liave been employed to expose tlie joint 
as the f- and V-'^'^'^P^^^^ tl^<^ c^'^^i'^^ semilunar, curvilinear, 
and longitudinal. OF these the straight or curvilinear incis- 
ion will afford ample space in excision of the joint. 

Oim-:ration An anoesthetic having been administered, 

the patient should be turned upon the sound side and the 
straight or curvilinear incision made, beginning one inch 
and a half above the summit of the great trochanter, carrying 
it downward along the posterior border and terminating two 
inches below the base of this eminence ; the wound should 
be from five to six inches in length and include section of 
all of the tissues to the bone ; a transverse incision should 
now be made in the periosteum, and, if possible, this mem- 
brane, with the points of insertion of the muscle into the 
greater and lesser trochanter should be detached by the ele- 
vator. In cases of chronic inflammation where the peri- 
osteum is thickened, this may be readily accomplished, 
otherwise it is quite impossible to effect this separation 
satisfactorily. If the points of insertion of the musi-Ies are 
not detached with the periosteum they should be divided 
with the probe-pointed bistoury. The position of the head 
of the femur having been ascertained by the finger, and the 
capsular ligament having been made tense by abducting the 
limb, it should be incised with the probe-pointed knife on 
its anterior and lower surface ; abduction, with external ro- 
tation, of the limb will dislodge the head of the femur, so 
that section of the ligamentum teres can be made and dis- 
articulation completed. The bone can now be protruded 
through the wound, care being taken that it is not fractured 
in the effort, the wooden shield slipped beneath it and sec- 
tion below the base of the trochanter made by the saw. If 
deemed desirable or more convenient, the bone may be 



764 EXCISION OF BONES AND JOINTS. 

freed by dissection, the cbain-saw passed beneath it and 
section made before disarticulation, which can be readily ef- 
fected afterwards by tlie probe-pointed knife. 

The section of the bone should always be made below the 
base of the great trochanter, whether this is involved in the 
disease or not, otherwise it will protrude into the wound and 
become a source of annoyance. The trochanter minor, if 
not diseased, may be left, and thus the attachments of the 
psoas magnus and iliacus internus muscles will be preserved. 
The finger should now be passed into the wound to ascertain 
the condition of the acetabulum ; if it is found to be involved 
the diseased portions should be removed by the forceps, 
gouge, or pliers, great care being taken to avoid wounding 
the periosteum and fascia which lines the interior of the 
pelvis and section of which will open the cavity. The 
cavity should now be carefully cleansed by douching with a 
warm antiseptic solution, the periosteum replaced, a drainage 
tube inserted, which will pass through the entire wound and 
the ends of which will appear at the upper and lower angles, 
or catgut threads, as shown in Fig. 22, the edges approxi- 
mated by sutures, antiseptic dressings applied and retained 
in position by a roller applied from the foot and terminating 
in the spica of the groin. Extension by weights and pulley 
should be made, the plaster stirrup having been adapted to 
the limb before the application of the roller (Fig. 137). 
Lateral support should be afforded by sand bags. A plaster 
dressing may be applied, with a fenestrum over the site of 
the wound, or the patient may be placed in the cuirass of 
Sayre. (Fig. 482.) Whatever the form of the splint em- 
ployed, the limb should be maintained in a position of ab- 
duction to prevent projection of the end of the femur. When 
consolidation has sufficiently advanced, the patient should be 



FEMUR SHAFT. 



700 



482. 



permitted to leave the bed and 
Avalk with the aid of crutches. 
In children under twelve years 
of age it is desirable to apply a 
fixed apparatus in order to obtain 
immobility of the parts. 

The prognosis after excision of 
the hip-joint is most unfavorable, 
as illustrated by the mortality 
tables. In gunshot wounds the 
mortality rate, as reported by 
Dr. Otis in the Surgeon-Gene- 
ral's Report, is 90.6 per cent. 
The mortality rate in excision for 
disease varies, according to the 
tables prepared by Dr. Hodges 
and others, from 45 to 53 per 
cent. The experience of Dr. 
Sayre is exceptional, 39 of his 59 
cases of excision for coxalgia hav- 
ing, as reported by him, recovered 
permanently. 

Amputation at the hip-joint 
gives a motality rate of nearly 90 
per cent. 



Femur Shaft. — Surgi- 
cal Anatomy — The shaft of the 
femur is covered by large muscu- 
lar masses which completely imbed it. These muscles con- 
sist chiefly of the rectus and crureus and sartorius in front, 
the sartorius, gracilis, vastus internus, and adductors on the 




766 EXCISION OF BONES AND JOINTS. 

inner side, the vastus externus on the outside, and the 
biceps, semi-membranosis, and semi-tendinosis behind. 

The femoral artery passes down the thigh, its course 
being indicated by a line drawn from the middle of Poupart's 
ligament to the inner side of the inner condyle ; at the 
junction of the middle with the lower third, it passes beneath 
the tendon of the adductor magnus muscle, and becoming the 
popliteal artery passes obliquely downward and outward be- 
hind the knee-joint. Above, the artery lies internal to the 
head of the femur, and becomes separated some distance from 
the bone as it passes to its termination. The arterial trunk 
lies in front, to the inside, and behind, as it passes in its 
course from Poupart's ligament to the knee-joint. The 
profunda femoris arises from the outer and back part of the 
common femoral, from one to two inches below Poupart's 
ligament, and passes from the outer to the inner side of the 
thigh terminating at the lower third. The internal saphenous 
vein occupies a position on the inside of the thigh lying 
between the two layers of the superficial fascia; its course is 
slightly to the inside of the femoral artery. 

The anterior crural nerve lies to the outside of the femoral 
sheath above and distributes a number of branches to the 
front and inside of the tliigh. The great sciatic nerve 
passes down on the posterior surface of the thigh, lying 
beneath the biceps and semi-tendinosis muscles. 

Excision of the femur may be performed for necrosis, 
compound comminuted fractures, and ununited fracture. 

The bone may be readily exposed by a longitudinal 
incision, made upon the outer side on a line with the great 
trochanter, reaching the bone between the attachments of the 
crureus and vastus externus muscles. 



TiniA — KNEE-JOINT. 767 

Operation. — In excisions performed for necrosis, the 
oj)enings into the sinuses may be enlarged in a direction to 
avoid wounding any important bloodvessel or nerve, tlie 
involucrum cut thorough with the pliers, and the sequestrum 
extracted with tlie bone forceps. In compound comminuted 
fractures, the detached fragments should be removed through 
the wound in the soft tissues. Excision for pseudarthrosis 
should be cautiously performed, a slight portion being 
removed, and the ends of the cut surfaces wired together. 

Great Trochanter Excision of this eminence may be 

performed by making a linear or slightly curved incision 
over its position. If the muscular attachments to the pro- 
cess remain, they should be divided and the diseased portions 
removed by the chisel, gouge, or pliers. The wounds after 
these operations sliould be drained, edges approximated, and 
dressings applied as in other excisions. In excision in com- 
pound comminuted fractures and for pseudarthrosis, the limb 
should be supported upon a suitable splint, by sand bags or 
by a plaster bandaage. 

Tibia Knee-joint Surgical Anatomy The 

condyles of the femur, above, the head of the tibia, below, 
with the patella in front, take part in the formation of the 
knee-joint. The tendon of the quadriceps extensor femoris, 
enveloping the patella, passes in front of the joint to its inser- 
tion in the tubercle of the tibia. On the outside, the tendon 
of the biceps muscle passes to the head of the fibula where 
it is inserted. On the inside the sartorius, gracilis, semi- 
tendinosis and semi-membranosis are placed, their points of in- 
sertion being in the internal tuberosity and anterior surface of 
the tibia. Behind, the two heads of the gastrocnemius, with 
the plantaris and popliteus muscles rest. On the surface of 



768 EXCISION OK BONES AND JOINTS. 

the posterior ligament, the popliteal artery, vein and inter- 
nal popliteal nerve are placed. The arterial distribution to 
the joint is derived from the anastomotic branch of the 
femoral, articular branches of the popliteal, and the recurrent 
branch from the tibial. Filaments from the obturator, 
anterior crural, external and internal popliteal nerves supply 
the articulation. 

Excision of the knee-joint may be performed in cases of 
chronic articular disease, compound fracture or dislocation, 
gunshot injuries and anchylosis in bad position. 

The H' U? cruical, and semilunar incisions have been 
employed to expose the joint. Of these the semilunar is 
the most satisfactory on account of the small wound pro- 
duced, and is made by carrying the knife from the posterior 
edge of the base of one condyle, below the border of the 
patella, to the posterior edge of the base of the other condyle. 
Through the angles of the wound, when the incision is thus 
made, drainage can be accomplished. 

Operation The limb being supported in an extended 

position, if the disease will permit, the incision should be 
made as above indicated, avoiding the internal saphenous 
vein on the inner side. The ligamentum patellse being di- 
vided, the flap is raised, the limb flexed, and the lateral and 
crucial ligaments severed, the latter with the probe-pointed 
knife to avoid wounding the posterior ligament and inflicting 
possible injury upon the popliteal vessels. The patella 
should now be dissected from its position, all restricting 
bands of tissue incised, and the ends of the femur and tibia 
protruded through the wound. The articular extremity of 
the femur should be removed by the Butcher saw, the blade 
being reversed and passed beneath the bone. The end of 
the tibia should be sawn off in the same manner. 



TI UI A — KN KE-JOl NT. 



09 



Ficr. 483. 




Tlie ordinary saw may be employed, the wooden spatula 
being placed beneatii the bones while section is made (Fig. 
483.) 

The amount of bone removed will depend in each case 
upon the conditions for which the operation is performed. 
In all cases where it is possible, 
more especially in the young, 
before union between the epi- 
physis and shaft has occurred, /^^ i ^ ^<is^\^ \\^ 
the point of section of the bone 

should fall some distance with- J^^^^K^*'^ jSHfi^ 1 

in the epipliyseal line, not ap- 
proach too near to it nor ex- 
tend beyond it. This injunc- 
tion is to be particularly ob- 
served in section of the femur, 
in order that the subsequent 

growth of the limb may not be interfered with ; it is also 
important, in connection with section of the tibia, but in less 
degree. The direction in which the section is made should 
also claim attention, in order that subsequent deformity may 
not occur. This may be accomplished by making the sec- 
tion parallel with the articular surfaces, or, as suggested by 
Billroth, in a " plane which, as regards the axis of the femur, 
is oblique from behind forwards, from below upwards, and 
within outwards." The section of the tibia should be made 
" transverse to the long axis of the bone, with a slight 
antero-posterior obliquity." 

If the hamstring tendons are in a state of contraction and 
prevent full extension of the limb they should be divided. 

The removal of the patella is deemed desirable, especially 
when the excision is performed for disease. In operations 



770 



EXCISION OF BONES AND JOINTS. 



made for injury, it may, if not involved, be permitted to 
remain ; as, however, it is of very little service and has been 
found in reported cases to prolong repair, it would be well, in 
all cases, to remove it. 

The hemorrhage caused by division of the articular vessels 
may be controlled by ligature, if necessary; the wound should 
be thoroughly cleansed by douching with antiseptic solu- 
tions, a drainage-tube passed through the wound so that the 
ends may appear at each angle, the wound closed by sutures, 
and antiseptic dressings applied. As anchylosis is desired 
after the operation, the cut surfaces of the bone should be 
placed in accurate apposition and so retained, if required, 
by drilling and introduction of strong wire. Absolute im- 
mobility of the limb should be secured by bandages and the 
adaptation of a splint of suitable character. Prof. Agnew 
prefers a plaster dressing which is applied while the patient 
is still under tlie influence of the anaesthetic. The wound 

Fig. 484. 




being protected by a piece of antiseptic gauze and the limb 
held in the extended position, the plaster bandages are ap- 
plied from the foot to the groin. When the plaster has set, 



TIIUA — KNKE-.TOINT. 



771 



the bandnges slioukl be cut over the front of the limb to 
prevent undue pressure, and above and below the knee to 
form sections, wliich may be raised and lowered so as to 
permit dressing of the wound without disturbing the limb. 
The limb may now be suspended by strips of muslin attached 
to a frame by cord and pulley (Fig. 484). The bracketed 
wire splint of Prof. Ashhurst may be employed (Fig. 485) 
or that of Price (Fig. 486). 

Fig. 485. 




In the absence of splints of this form the long fracture box 
may be used. Recovery, after knee-joint excision, is very 
slow, requiring from eight to nine months for its completion. 



Fm. 486. 




The results, as to the condition and function of the limb, 
present great varieties, as shown in the shortening of the 
limb, position, and character of the union, as well as its 



772 EXCISION OF BONES AND JOINTS. 

function in supporting weiglit and tolerating pressure and 
movement. The permanence of the results cannot be defi- 
nitely determined until some time has elapsed, usually a 
year or more. Age exerts a very marked influence in de- 
termining the results, as seen on examination of the statis- 
tical tables, the mortality-rate being highest in subjects 
under Jive and over thirty years. Gunshot injuries in mili- 
tary service give a very high mortality-rate, 68 to 90 per 
cent. ; in civil practice 39 to 42 per cent. Excisions for 
disease return a rate of from 20 to 32 per cent. ; in subjects 
between five and ten it is reduced to 16.2 per cent. The 
mortality-rate in excivsions for bony anchylosis is very 
favorable, not exceeding 25 per cent. In excisions of tiie 
knee-joint, as in those of other joints, consecutive amputa- 
tion is necessary in a certain proportion of cases ; complete 
impairment of function occurs also in some. 

Tibia and Fibula — Shaft Surgical Anatomy. 

— The outer portion of the anterior surface, witli the outer 
and posterior surfaces of the bones of the leg, are covered by 
the flexor, extensors, abductors, and adductors of the foot. 
The anterior tibial artery descends upon the anterior surface 
of the interosseous membrane and of the tibia, to the front 
of the ankle-joint. The posterior tibial and its branch, the 
peroneal, pass down upon the posterior surface of the leg rest- 
ing upon the tibialis posticus muscle. The posterior tibial 
descends to the fossa between the internal malleolus and heel, 
and thence to the sole of the heel, where it divides into the 
internal and external plantar arteries. The peroneal artery 
occupies a position along the inner border of the fibula, termi- 
nating at the ankle-joint. The anterior tibial and musculo- 
cutaneous nerves are placed on the anterior surface of the leg, 



TIBIA AND FIBULA. 



773 



Fi^. 487. 



the former accompanying and lying to tlie outer side of the 
anterior tibial artery ; the latter lies on the fibular side of the 
leg and terminates in branches to the dorsum of the foot and 
toes. The posterior tibial nerve runs in connection with the 
posterior tibial artery lying to its outer side. The internal 
saphenous vein ascends the leg along the inner side, passing 
in front of the internal malleolus, and lying behind the inner 
border of the tibia accompanied in its course by the internal 
saphenous nerve. 

Excision of the bones of the leg may be demanded for 
necrosis, compound comminuted fractures, ununited frac- 
tures, and deformity. 

The bones may be exposed by longitudinal incisions made 
over their position ; that for the tibia, upon the anterior sur- 
face or spine, and that for 
the fibula, upon the outer 
side of the leg (Fig. 487). 

Operation The 

bones having been ex- 
posed by the incision, the 
periosteum should be de- 
tached, the bone divided, 
and the portion removed. 
In necrosis, the dead bone 
may be removed by the 
chisel, gouge, and forceps, 
and in caries, by the chisel 

or burr of the surgical engine ; in compound fractures, the 
protruding portions of bone may be removed by the saw or 
pliers, if necessary ; detached fragments, in comminuted 
fractures, should be picked out with the forceps ; in ununited 
fracture, occurring in the tibia, both bones should be excised 

65* 




774 EXCISION OF BONES AND JOINTS. 

in order to secure union. In excision of the fibula the 
malleolus if possible sliould be preserved in order that the 
outer support of the ankle-joint may not be removed and 
thus permit eversion of the foot. 

Hemorrhage having been controlled, the wound washed 
out, drainage provided for, sutures introduced, and antiseptic 
dressings applied, the leg should be placed in a fracture-box 
and proper support afforded until repair occurs, so that de- 
formity may not ensue. When repair has sufficiently ad- 
vanced a plaster bandage may be applied, and the patient 
allowed to walk on crutches. The mortality-rate in exci- 
sions of the bones of the leg is very favorable, being 20.34 
per cent., as ascertained by Dr. S. W. Gross, in gunshot 
injuries, and 16.8 for all conditions outside of shot injuries, 
as recorded by Heyfelder. 

Tibia, Fibula, and Astragalus Ankle-joint — 

Surgical Anatomy The bones entering into the forma- 
tion of the joint are the tibia, fibula, and astragalus. The 
structures in relation with this joint are, in front, the tibialis 
anticus, extensor proprius pollicis, anterior tibial vessels, 
anterior tibial nerve, extensor communis digitorum, peroneus 
tertius in order from within outward ; behind, tibialis pos- 
ticus, flexor longus digitorum, posterior tibial vessels, pos- 
terior tibial nerve, flexor longus pollicis, in position from 
within outward. These structures maintain the same rela- 
tions on the inner side. In the groove behind the external 
malleolus, the tendons of the peroneus longus and peroneus 
brevis pass. 

Branches from the anterior tibial and peroneal arteries 
supply the joint. The nerves are derived from the anterior 
tibial. 



TIBIA, Fir.ULA, AND ASTRAGALUS ANKLE-JOINT. //O 

The conditions wliich require excision of the ankle-joint 
are articuh\r disease, compound fractures or dislocations, and 
gunshot injuries. 

The joint may be exposed, preferably, by an incision on 
the outer side, curvilinear in shape, beginning three inches 
above the end of the external malleolus, along the posterior 
border of the fibula, carried downward behind the malleolus, 
and terminating within half of an inch of the base of the 
fifth metatarsal bone. If the joint is extensively involved, 
a similar incision may be made on the inner aspect of the 
leg and foot, terminating at the internal cuneiform bone. 

Operation To permit satisfactory inspection of the 

parts during the operation, the circulation may be con- 
trolled by Esmarch's bandage. The incision on the outside 
having been made as above described, the flap is dissected 
up, the tendons of the peroneus longus and brevis being 
carefully avoided. The fibula, which is exposed, may be 
divided with the pliers or saw, and the connections of the 
detached portion severed. The joint may now be inspected 
and the diseased portions of the astragalus and tibia removed 
by the chisel or gouge. If the disease is extensive, the inner 
incision along the tibia may be made, and the flaps carefully 
dissected in order to avoid injury to the structures placed on 
the inner side, consisting of the tibialis posticus, flexor longus 
digitorum, with the posterior tibial vessels and nerve. These 
being displaced and held away, the deltoid ligament may 
be detached, or the extremity of the internal malleolus divided 
with the pliers. The malleolus being isolated, the surfaces 
of the tibia and astragalus can be inspected by everting the foot 
strongly. The internal malleolus can be divided by passing 
a metacarpal or Adams saw through the wound behind the 
tibia, and sawing from behind forward. The articulating 



776 EXCISION OF BONES AND JOINTS. 

surface of the astragalus may be removed in like manner, or, 
if necessary, it may be dissected out and removed entirely. 
An effort should be made in this operation to preserve the 
periosteum in order to obtain bone reproduction. Ligature 
of one or more vessels may be required, after which the 
wound should be douched with warm antiseptic lotions, a 
drainage tube passed entirely through it, the edges approxi- 
mated by sutures, antiseptic dressings applied, and the limb 
placed in a fracture-box, the foot being carefully secured to 
the foot-piece at the proper angle to the leg. Instead of 
the fracture-box, plaster dressings may be applied, fenestra 
being cut in the sides to permit of inspection and dressing 
of the wound (Fig. 91). 

The after-treatment should be conducted as in other ex- 
cisions, passive motion being instituted so as to obtain a 
short ligamentous union — anodynes, stimulants, tonics and 
good food being given as needed. Four to five months are 
required to perfect recovery. 

The mortality-rate in ankle-joint excision is about 20 per 
cent., a rate higher than that in amputations at the joint, 
which vary from 6 to 9 per cent. 

Tarsus, Metatarsus, and Phalanges. — Surgical 
Anatomy. — The tarsus consists of seven bones, the os 
calcis, astragalus, cuboid, scaphoid, and internal, middle, 
and external cuneiform bones. They are divided into two 
rows, the os calcis and astragalus constituting the first, and 
the cuboid, scaphoid, and three cuneiform bones the second 
row. The os calcis articulates above, with the astragalus, 
and in front, by its anterior surface with the cuboid. The 
astragalus is placed between the bones of the leg above, the 
OS calcis below, and articulates by its head with the scaphoid 



TARSUS. 777 

in front. The cnhoid occupies a position on the outside of 
the foot, articulating behind with the os calcis, on the 
inside with the scaphoid and external cuneiform, and in 
front with the fourth and fifth metatarsal bones. The 
scaphoid is placed on the inner side of the foot, articulating 
behind with the astragalus, on the outer surface with the 
cuboid, and in front with the internal, middle and external 
cuneiform bones. The three cuneiform bones are placed on 
the inner aspect of the foot, articulating behind with the 
scaphoid, in front with the bases of the first, second, third, 
and fourth metatarsal bones, and on the outside with fhe 
cuboid. 

On the anterior surface of the tarsus, the tendons of the 
tibialis anticus, extensor proprius poUicis, and extensor 
longus digitorum, with the body of the extensor brevis 
digitorum, tlie dorsalis pedis artery, and terminal branches 
of the anterior tibial and musculo-cutaneous nerves are 
placed. The tendons of the peroneus longus and brevis pass 
on the outer side, behind the external malleolus, and on the 
outside of the cuboid bone, the former traversing the sole of 
the foot to its point of insertion in the base of the first meta- 
tarsal bone. On the inside, the tendons of the tibialis posti- 
cus, flexor longus digitorum, and flexor longus poUicis, with 
the posterior tibial vessels and nerves, pass to the sole of the 
foot. The under surface of the tarsus is covered by a thick 
mass of muscular structures, composing the muscles of the 
plantar region, with the external and internal plantar 
arteries and nerves. Of the bones of the tarsus, the astraga- 
lus alone has no muscular attachments, although its surface 
is grooved for the passage of tendons. In operations upon 
the bones of the tarsus the relation of the bones, one to the 
other, and of the tendinous, vascular, and nervous structures, 



778 EXCISION OF BONES AND JOINTS. 

should be borne in mind in order that they may not be 
injured. 

The astragalus, os calcis, and scaphoid are more frequently 
involved in injuries and diseases than the remaining bones 
of the tarsus, and are in consequence more frequently the 
subject of operation. 

The conditions requiring excision, partial and complete, 
of the tarsal bones are articular disease, compound fracture 
and dislocation, caries, necrosis, and gunshot injuries. 

They may be exposed by straiglit or curved incisions 
made over their positions, care being taken, in raising the 
flaps, to avoid injury to the tendons which are usually in 
relations with them. 

Operation Astragalus The bone may be readily 

reached by a semilunar incision over the outer and anterior 
surface of the ankle-joint dividing the integument and fascia. 
The tendons of the extensor muscles, and dorsalis pedis artery, 
on being exposed, should be held out of the way or divided 
and the neck of the astragalus severed by strong cutting pliers. 
The head of the bone being detached from the scaphoid is 
removed and the body of the bone may be seized with the 
lion-jawed forceps, and while forcible traction is made in 
various directions the ligaments should be divided by a strong 
probe-pointed knife, w^hich should be kept in close contact 
with the surface of the bone. If the bone is disintegrated 
by disease it will be necessary to remove it by the gouge and 
forceps. Tlie articular ends of the tibia and fibula may be 
exposed in this operation by extending the incision upward 
on the outer side behind the external malleolus. Removal 
of the ends may be effected by tlie pliers or chain saw, the 
foot being moved in such direction as to expose them fully. 

Os Calcis This bone may be exposed by an incision 



TARSUS — OS C ALOIS. 



779 



Fiff. 488. 



across the sole of tlie heel, similar to that employed in 
Syme's amputation at the ankle-joint. The incision suggested 
and practised by Mr. Erichsen is preferable, as by it the 
wounding of important structures is avoided and the cicatrix 
is not exposed to pressure. The patient being in the prone 
position, the knife is entered three-quarters of an inch 
behind the tuberosity of the fifth metatarsal bone and carried 
backward around the heel below the position of the posterior 
tibial artery, the incision terminating about opposite the 
tuberosity of the scaphoid bone on the 
inner side of the foot. The incision should 
be made through the skin and fascia, and 
the tendons of the peronei muscles care. 
fully avoided in their position on the outer 
side of the cuboid bone. The flap is to 
be dissected from the bone and reflected. 
A vertical incision should now be made 
over the tendo Achillis, joining the first, 
and the tissues removed from the tendon 
and its attachment to the os calcis severed. 
The interosseous ligament, unitino- the os 
calcis and astragalus, should now be divided 
by carrying the knife upward over the 
posterior surface of the bone, which is 
now seized by the lion-jawed forceps and 
strongly retracted, while the lateral liga- 
ments are divided. The long calcaneo- 
cuboid ligament is now divided, and the bone, being free, 
is removed (Fig. 488). 

Subperiosteal excision of the bone may be performed, as 
practised by Oilier, the periosteum, with the tendons, being 
raised by the elevator. 




780 



EXCISION OF BONES AND JOINTS. 



Fiff. 489. 



Both the OS calcis and astragalus may be removed by the 
same incision as that employed in excising the os calcis, the 
flaps being dissected up laterally so as to expose the malleoli. 
The tendo Achillis is to be divided, then the external lateral 
ligament and the external malleolus severed with the pliers 
and removed. The internal lateral ligament being rendered 
tense, by strongly abducting the foot, it should be severed 
by the probe-pointed knife and the malleolus divided and 
removed, care being taken, in the incisions made upon this 
side, to avoid the posterior tibial vessels. Disarticulation 
of the OS calcis from the cuboid, and the astragalus from the 
scaphoid may nov\r be effected and the bones removed. 

Cuboid, Scaphoid, and Cuneiform Bones — These 
bones may be excised separately, or together by straight or 

curved incisions over the 
dorsal surface of the foot 
(P^ig. 489). The tendons 
overlying them should be 
held out of the way and the 
articulation being sepa- 
rated, the bones may be re- 
moved by the forceps. If 
extensively invaded by dis- 
ease they may be removed 
by the chisel or gouge. 
Entire Tarsus — Involvement of all of the bones of the 
tarsus in disease occurs in some instances and demands their 
excision. Three successful operations of this character 
have been reported by Prof. P. S. Conner, of Cincinnati, 
two of which were performed by him. Excision may be 
effected by the lateral incision upon the outer surface, or, if 
necessary, one may be made upon each side. If the incision 




^lETATAHSUS. 781 

across the dorsum is made it involves division of the extensor 
tendons, which should, after the excision, be united by suture. 

In excision of the bones of the tarsus, partial or complete, 
the wound should be thoroughly cleansed, a drainage tube 
carried through from side to side to accomplish efficient 
drainage, tlie edges of the wound approximated by sutures, 
antiseptic dressings applied, and the limb placed in the 
fracture box or the plaster bandage. If the periosteum has 
been preserved reproduction of bone may occur. Eecovery 
after tarsal excisions is very slow, requiring from five to six 
months. The results following excision of the bones of the 
tarsus are, as a rule, very favorable, both as regards the use- 
fulness of the limb and the mortality-rate. In excisions of 
the astragalus, the rate of mortality varies from 14 to 18 per 
cent. In excisions of the os calcis the mortality does not 
much exceed 15 per cent. In operations upon the cuboid, 
scaphoid, and cuneiform bones the rate is 14.2 per cent. 

In 108 excisions of the tarsus, partial and complete, re- 
corded by Prof. Conner, in 45 the result Avas very good ; in 
23, good; in Q,fair; in 10 , failures ; in 12, uncertain; in 
1, unknown — making the percentage of recoveries 88.89. 
In 11, death occurred, giving a mortality-rate of 10.18 per 
cent. In two excisions of the entire tarsus, performed by 
him, the results were most satisfactory, the patients being 
able, after recovery, to walk without limp and without the 
aid of support and to engage in the most active employments. 
Shortening of the limb occurred to the extent of one-half to 
three-fourths of an inch, and of the foot from two and a half 
to three inches. 

Metatarsus. — Surgical Anatomy The metatarsal 

bones are placed between the cuneiform and cuboid bones 
66 



782 



EXCISION OF BONES AND JOINTS. 



and the phalanges, and are covered on the dorsal surface by 
the extensor tendons of the toes. The under surfaces are 
covered by the muscles of the plantar region. The dorsalis 
pedis artery gives off the metatarsal branch which passes to 
the outer border of the foot across the bases of the metatarsal 
bones and forms an arch from which the interosseae arise. 
These branches, three in number, pass forward upon the 
three outer dorsal interossei muscles and in the clefts of the 
toes divide into two dorsal branches for the adjoining toes. 
The external plantar artery forms an arch across the sole of 
the foot on the bases of the metatarsal bones, anastomosing 
between the bases of the first and second with the communi- 
cating branch of the dorsalis pedis, and gives off four digital 
branches, which are distributed to the outer side of the 
second toe and the outer toes, both sides of the great toe and 
the inner side of the second being supplied by the communi- 
cating branch of the dorsalis pedis artery. The nerves on the 
dorsal and plantar surfaces follow the course of the arteries. 

The conditions demanding excision of the metatarsal 
bones are caries, necrosis, compound fractures, and compound 
dislocations. 

The bones should be exposed by straight or curvilinear 
incisions over the dorsal surface (Fig. 490), the tendons and 

bloodvessels being carefully 



Fig. 490. 




avoided. 

Operation. — The bone 
being exposed, it should be 
divided with the pliers, 
freed by dissection from the 
surrounding tissues and dis- 
articulated, care being taken 
to avoid wounding the ar- 



:\iETATAiisrs. 783 

teries of tlie plantar region. Sitb-peri osteal -^^xcision may be 
performed in cases of necrosis and other conditions. In 
caries, the gouge and chisel should be employed to remove 
the diseased bone. After the application of dressings the 
limb should be placed in a fracture-box. The bases of the 
metatarsal bones have been excised, with the bones of the 
tarsus, for disease implicating both. 

Phalanges — Excisions of the phalanges are limited to 
those of the metatarso-phalangeal articulation of the great 
toe and to the bones of the third row, which can be exposed 
by incisions upon the plantar or lateral surfaces. In com- 
pound fractures the fragments can be dissected out and re- 
moved by the forceps. Excision of the metatarso-phalangeal 
articulation of the great toe has been performed in cases of 
necrosis. 

After the application of dressings, the foot should be kept 
at rest, if necessary, in a plaster splint or in the fracture- 
box. 



INDEX. 



Acid, carbolic, solutions of, 35 i . 

salicylic, 47 I 

Adhesive plaster, 20 I 

cutting, into strips, method 

of, 20 
heating of strips, 21 
length'of strips, 20 | 

removal of strips, 21 
Avidth of strip, 20 
Alcohol dressing, 57 
Alumina, acetate of, 49 

aceto-tartrate of, 49 
Amputations. 568 

affection of stumps after, 600 
after-treatment in, 597 
antiseptic treatment in, 598 
case of instrument for, 580 
circular method of, 580 
condition demanding, 568 
constitutional effects after, 607 
flap method, 591 
instruments used iU; 571 
intermediary stage in, 570 
intra-uterine, 607 
knives used in, 572 
lower extremity, 610 
method of using the saw in, 

582 
methods of controlling hemor- 
rhage in, 576 
of ligaturing arteries in, 
583 
modified circular method in, 

590 
mortality-rate after, 6C8 
open method, treatment by, 

600 
oval method, 594 
pneumatic aspiration, treat- 
ment by, 599 
primary stage in, 570 

66^ 



imputations — 

re-amputations, 607 
rectangular flap method of, 

595 
rules for performing, 608 
Scoutetten's method, 594 
secondary stage in, 571 
special, 610 
svnchronous, 605 
teale's method, 595 
Tripier's operation, 624 
upper extremity, 662 
arm, 686 

anatomy of, surgical, 686 
lower third, rectangular flap 

method, 688 
lower or middle third, circular 

method, 688 
upper, middle, or lower third, 
single flap method, 689 
double flap method, 689 
elbow-joint, 682 

anatomy of, surgical, 682 
circular method, 684 
single flaj) method, 685 
foot, 610 

anatomy of, surgical, 610 
Chopart's operation, 622 
great toe, oval method, 614 
Hey's operation, 021 
Lisfranc's operation, 618 
little toe, oval method, 616 
medio-tarsal articulation, 622 
metatarsal bones, in conti- 
nuity of, flap method, 617 
metatarso-phalangeal articu- 
lation, oval method, 614 
Piroffoff's operation, 629 
Syme's operation, 626 
tarso-metatarsal articulation, 
flap method, 618 



786 



INDEX. 



Amputations, foot — 

tibio-tarsal artieulatioti , 626 
toes, 613 

all of the toes, 016 
at articulations, 613 
in continuity of bones, 614 
forearm, 678 

anatomy of, surg-ical, 678 
lower third, circular method, 
680 
modified circular method, 

681 
rectangular flap method, 
681 
middle third, single flap 

method, 682 
middle or upper third, double 
flap method, 682 
hand, 6()2 

anatomy of, surgical, 662 
carpo-metacarpal articula- 
tion, leaving the thumb, 
single flap method, 673 
fingers, 665 

all of the fingers, at the 
metacarpo-phalangeal ar- 
ticulation, 670 
at ai'ticulations, double flap 
method, 667 
circular method, 667 
oval method, 668 
single flap method, 666 
in continuity of bone, 668 
index finger, at metacarpo- 
phalangeal articulation, 
oval method, 669 
little finger, at metacarpo- 
phalangeal articulation, 
oval method, 669 
metacarpal bones, in conti- 
nuity of, flap method, 673 
metacarpo-phalangeal articu- 
lation, circular method, 
669 
lateral flap method, 669 
oval method, 668 
thumb, 671 

at carpo-metacarpal articu- 
lation, oval method, 672 
single flap method, 672 
hip-joint, 651 



Amputations, hip-joint — 

anatomy of, surgical, 651 
controlling hemorrhage in , 661 
circular method, 659 
double flap method, 656 
double lateral flap method, 

657 
Furneaux Jordan's method, 

660 
modified circular method, 659 
oval method, 658 
sinele anterior flap method, 
655 
knee-joint, 637 

anatomy of, surgical, 637 
Bauden's method, 642 
circular method, 641 
long anterior and short poste- 
rior flap, retaining the 
patella, 639 
oval method, 642 
short anterior and long poste- 
rior flap, 641 
leg, 631 

anatom}^ of, surgical, 631 
lower third, circular method, 
633 
rectangular flap method, 

635 
Teale's method, 635 
middle and upper third, dou- 
ble flap method, antero- 
posterior, 636 
middle and upper third, long 
external and short internal 
flap method, 637 
shoulder-joint, 689 

anatomy of, surgical, 689 
controlling hemorrhage in, 

695 
double flap method, 694 
Dupuytren's method, 693 
Larrey's method, 691 
Lis franc's method, 694 
oval method, 691 
single flap method, 693 
Spence's operation, 693 
thigh, 642 

anatomy of, surgical, 643 
Garden's operation, 645 
circular method, 649 



INDKX. 



78/ 



Amputations, thiirh — 

(iritti's operation, 045 
lateral flaps, (U7 
lonic anterior flap, 64:8 
lower third, antero-posterior 

flaps, 64G 
middle third, 051 
modified circular method, 650 
rectangular flap method, (US 
Se.lillot's operation, (WS 
throuijh base of the condyles, 

645^ 
upper third. 051 
wrist-joint, 074 

anatomy of, surgical, 674 
circular method, 070 
double flap method, 077 
siniile flap method, 677 
Antiseptic gauze, 30 

methods, modification of, 50 
system of dressing wounds, 35 
Aorta, abdominal, 530 
anatomy of, surgical, 530 
ligature of, 537 
Apparatus, Sayre's suspension, 118 
Arteries, ligature of, 470 
Artery, axillary, 518 

anatomy of, surgical, 518 
ligature of, in first portion, 520 
in third portion, 521 
brachial, 523 

anatomy of, surgical, 523 
ligature of, above median 
nerve, 520 
below median nerve, 526 
brachial, at bend of elbow^, 537 
anatomy of, surgical, 527 
ligature of, 528 
carotid, common, 499 
anatomy of, surgical, 499 
ligature of, above omo-hyoid 
muscle, 502 
below omo-hyoid muscle, 
503 
carotid, external, 505 

anatomy of, surgical, 505 
ligature of, 500 ^ 
carotid, internal, 512 

anatomy of, surgical, 512 
ligature of, 513 
dorsal is pedis, 560 

anatomy of, surgical, 500 



Arter}', dorsalis pedis — 

liarature of, 51)1 
facial, 509 

anatomy of, surgical, 509 

ligature of, 510 
femoral, common, 545 

anatomy of, surgical, 545 

ligature of, 548 
femoral, superficial. 550 

ligature of, at apex of Scarpa's 
triangle, 550 
in Hunter's canal, 551 
gluteal, 543 

anatora}' of, surgical, 543 

ligature of, 543 
iliac, common, 538 

anatomy of, surgical, 53S 

ligature of, 540 
iliac, external, 540 

anatomy of, surgical, 540 

ligature of, 541 
iliac, internal, 541 

anatomy of, surgical, 541 

ligature of, 542 
innominate, 493 

anatomy of, surgical, 493 

ligature of, 495 " 
lingual, 508 

anatomy of, surgical, 508 

li2:ature of, 509 
occipital, 511 

anatomy of, surgical, 511 

ligature of, 512 
peroneal, 500 

anatomy of, surgical, 500 

ligature of, 567 
popliteal, 551 

anatomy of, surgical, 551 

ligature of, in upper third, 554 
lower third, 555 
pudic, internal, 544 

anatomy of, surgical, 544 

ligature of, 545 
radial, 529 

anatomy of, surgical, 529 

ligature of, in upper thii'd, 530 
middle third, 531 
lower third, 531 
on outer side of wrist, 532 
anatomy of, surgical, 532 
ligature of, 532 
sciatic, 543 



788 



INDEX. 



Artery, sciatic — 

anatomy of, surgical, 543 
ligature of, 544 
subclavian, 513 

anatomy of, surgical, 513 
ligature of, 516 
temporal, 510 

auatom}^ of, surgical, 510 
ligature of, 511 
thyroid, superior, 507 
anatomy of, surgical, 507 
ligature of, 508 
tibial, anterior, 556 

anatomy of, surgical, 556 
ligature of, in upper third, 558 
middle third, 559 
lower third, 559 
tibial, posterior, 562 

anatomy of, surgical, 562 
ligature of, in upper third, 564 
middle third, 565 
lower third, 565 
at the ankle, 566 
ulnar, 533 

anatomy of, surgical, 533 
ligature of, in upper half, 534 
middle of forearm, 535 
lower half, 536 
Ashes, coal, 17 

Bandages — Bandaging, 65 
arm, 92 
circular, 70 

of the abdomen, 86 

of the eyes, 73 

of the forehead, 72 

of the forearm or arm, 93 

of the neck, 80 

of the wrist, 92 
compound, 102 
crossed, of angle of the jaw, 74 

of one breast, 83 

of both breasts, 84 

of one eye, 73 

of both eyes, 74 
Desault's, 100 
dextrine. 111 
figure-of-8, 72 

of ankle, 95 

anterior of chest, 80 

posterior of chest, 82 

of elbow, 92 



Bandages, f5gure-of-8 — 

of knee, 95 

of neck and axilla, 80 

of thighs, 96 

of wrist, 92 
French spiral, 98 
general, 9S 
Gibson's, 78 
head, of the, 72 
immovable, 108 

application of, 111 

removal of, 112 
in treatment of wounds, 63 
inferior extremity covering the 

heel, 97 
invaginated, 103 
knotted, of the head, 75 
length of, for the body, 67 

for the extremities, 67 

for the hand, 68 

for the head, 67 
machine for rolling, GQ 
method of applying, 68 

of fastening, 68 
oblique, 70 

of forearm or arm, 93 
plaster-of-Paris, 109 

preparation of, 109 
recurrent, 72 

for amputations, 99 

of the head, 76-77 
Rhea Barton's, 78 
rolling, 66 
Scultetus, 98 
silica, 111 
simple, 65 
sling, 104 
spica, 72 

of one or both groins, 87 

of the instep, 96 

of the shoulder, 85 

of the thumb, 91 
spiral, 70 

of the abdomen, 86 

of the arm, 93 

of the chest, 86 

of the flno-er, 89 

of all of the fingers, 90 

of the palm, 91 
spiral-reverse, 70 

of the lower extremity, 97 

of the upper extremity, 93 



IXOKX. 



789 



Baiulaui •?-, spiral-revorsc — 
of the penis, 8!) 

St a re h, 108 

sublimated, 54 

superior extremity, 80 

suspensory. 104 

T, 1U:3 

tio-ht, cranjrrene from, 60 

tnpolith, 111 

trunk, of the, 79 

Velpeau's, 100 

wet, application of, 68 
Bismuth, subnitrate of, 51 
Boro-salieylic solution, 55 
Bran, 16 

Cataplasms, 2'd 

Catgut ligatures, sublimated, 54 

sutures, sublimated, 54 
Charcoal, 17 
Charpie, 14 

Cleanliness in wounds, 61 
Clove hitch, formation of, 108 
Compresses, 13 

cribriform, IS 

graduated, 19 

pyramidal, 10 
Corrosive sublimate, 52 

operations performed with, 53 
Cotton-wool, 14 

absorbent, 14 

hj-groscopic, 14 

salicylated, 47 
Curettes, 45 

Director, grooved, 48 
Dislocations, 299 
causes of, 301 

exciting, 302 

predisposing, 301 
complicated, 313 
compound, 314 
definition of, 299 
diagnosis of, 307 
pathological characters in, 303 
prognosis in, 308 
special, 320 
symptoms of, 305 
treatment of, 309 
varieties of, 299 

couLjenital, 301 

pathological, 300 



Dislocation?, varieties of — 
traumatic, 290 
bilateral, 300 
complete, 209 
complicated, 299 
consecutive, 300 
double, 300 
incomplete, 299 
old, 300, 317 
primitive, 300 
simple, 299 
single, 300 
recent, 300 
unilateral, 300 
face, 320 

lower jaw, 320 
hyoid bone, 333 
lower extremity, 416 
astragalus, 465 
anomalous of, 470 
compound of, 469 
ankle-joint, 458 
cuboid, 470 
cuneiform bones, 471 
hip-joint, 416 

anomalous of, 439 
complications in, 440 
congenital of, 443 
diagnosis, differential, 430 
incomplete, 439 
old, 440 

reduction in, by maniijula- 
tion, 431 
by extension, 436 
subluxation, 440 
varieties of displacement in, 
419 
iliac, 422 
ischiatic, 423 
pubic, 426 
thyroid, 425 
inferior tibio-fibular articula- 
tion, 457 
knee-joint, 447 

complicated of, 453 
compound of, 453 
congenital of, 454 
metatarsus, 471 
OS calcis, 470 
patella, 443 
phalanges, 473 
scaphoid, 470 



'90 



INDEX. 



Dislocations, lower extremit}' — 
semilunar cartilao:es, ^o-l 
subastragaloid, 468 
superior tibio-fibular articula- 
tion, 456 
tarsus, 463 
pelvis, 412 
coccyx, 413 
pubes, 412 
sacrum, 412 
ribs and costal cartilages, 335 
sternum and ensiform cartilage, 

337 
upper extremity, 339 

acromio-clavicular articula- 
tion, 344 
carpus, 398 
clavicle, 339 
elbow-joint, 380 
humerus and ulnar, 378 
inferior radio-ulnar articula- 
tion, 391 
metacarpus, 402 
phalanges, 405 
scapula, 348 
shoulder-joint, 349 
biceps muscle, tendon of, 

371 
double, 367 
complicated, 366 
compound, 366 
congenital, 371 
old, 367 

paralysis of deltoid follow- 
ing, 365 
sterno-clavicular articulation , 

339 
superior radio-ulnar articula- 
tion, 373 
thumb, 402 

compound of, 411 
wrist-joint, 394 
vertebnK?, 326 
Drainage, perfect, 60 
with catgut threads, 38 
with decalcified bone tubes, 39 
with horse-hair, 39 
Drainage-tubes, 37 
Dressing cases, surgical, 58 
Dressings, surgical, 13 
Guerin's cotton-wool, 56 
sublimated extemporaneous, 56 



Earth, dry, 16 
Esmarch's bandage, 576 
Eucalyptus oil, 49 

ointment, 47 
Excisions, 697 

after-treatment in, 708 
conditions demanding, 698 
pathological, 698 
traumatic, 698 
contra-indications, 699 
incisions to be made, 703 
instruments required in, 700 
process of repair after, 699 
section of bone in, 705 
special, 709 
cranium, 709 

anatomy of, surgical, 709 
conditions demanding, 710 
incisions, 713 
instruments, 712 
operation, 713 
face, bones of, 717 
lower jaw, 726 

anatomy of, surgical, 726 
incisions, 726 
operation, 726 
malar bone, 717 
anatomy of, surgical, 717 
conditions demanding, 717 
incisions, 717 
operation, 717 
upper jaw, 717 

anatomy of, surgical, 717 
I conditions demanding, 718 

I incisions, 720 

instruments, 719 
operation, 722 
. lower extremity, 762 

ankle-joint, 774 
I anatomy of, surgical, 774 

conditions demanding, 775 
incisions, 775 
operation, 775 
femur, shaft of, 765 
anatomy of, surgical, 765 
conditions demanding, 766 
incision, 766 
operation , 767 
great trochanter, 767 
hip-joint, 762 

anatomy of, surgical, 7(52 
conditions demanding, 7(52 



INDEX. 



791 



Excisions, hip-joint — 

incisions, 763 

operation, 763 
knee-joint, 767 

an atom}' of, surgical, 767 

conditions demanding, 768 

incisions, 7(58 

operation, 768 
metatarsus, 781 

anatomy of, surgical, 781 

conditions demanding, 782 

incisions, 782 

operation, 782 
phalanges, 783 

tarsus, metatarsus, and pha- 
langes, 776 

astragalus, operation, 778 

conditions demanding, 778 

cuboid, scaphoid, and cunei- 
form bones, 780 

entire tarsus, operation, 780 

incisions, 778 

OS calcis, operation, 778 

tarsus, anatomy of, surgi- 
cal, 776 
tibia and fibula, shaft of, 772 

anatomy of, surgical, 772 

conditions demanding, 773 

incisions, 773 

operation, 773 
trunk, 731 
pelvic bones, 73i 

anatomy of, surgical, 73-t 

conditions demanding, 734 

incision, 73i 

operation, 734 
coccyx, 735 

operation, 735 
ribs and costal cartilages, 732 

anatomy of, surgical, 732 

conditions demanding, 732 

incision, 733 

operation, 733 
sternum and ensiform cartil- 
age, 731 

anatomy of, surgical, 731 

conditions demanding, 731 

incision, 732 

operation, 732 
upper extremity, 735 
carpus, metacarpus, and pha- 
langes, 760 



Excisions, carpus, metacarpus — 

anatomy of, surgical, 760 

conditions demanding, 760 

incisions, 760 

operation, 761 
clavicle, 735 

anatomy of, surgical, 735 

conditions demanding, 736 

incision, 736 

operation, 736 
elbow-joint, 749 

anatomy of, surgical, 749 

conditions demanding, 750 

incisions, 750 

operation, 750 
humerus, shaft of, 747 

anatomy of, surgical, 747 

conditions demanding, 748 

incision, 748 

operation, 748 
scapula, 738 

anatomy of, surgical, 738 

conditions demanding, 738 

incision, 739 

operation, 739 
shoulder-joint, 742 

anatomy of, surgical, 742 

conditions demanding, 743 

incisions, 743 

operation, 743 
radius and ulna, shaft of, 752 

anatomy of, surgical, 752 

conditions demanding, 753 

incisions, 753 

operation, 754 
wrist-joir.!-, 754 

anatomy of, surgical, 751 

conditions demanding, 755 

incisions, 755 

operation, 756 

Forcei)s, artery, 574 
dissecting, 30 
dressing, 29 
Fractures, 117 

adhesive plaster in treatment 

of, 139 
after-treatment of, conditions 

occurring during, 143 
causes of, 121 
exciting, 121 
predisposing, 121 



792 



INDEX. 



Fractures — 

cbanoring bed-liuen in, 131 
complicated, treatment of, 144 
compound, treatment of, 145 
contusions and extravasa- 
tions in, 143 
definition of, 117 
diagnosis of, 124 
direction of line of, 120 

longitudinal, 120 

oblique, 120 

transverse, 120 
displacement in, 123 
gangrene in, 143 
inflammation, erysipelas, 

tetanus, surgical fever, 

and pyaemia in, 143 
passive motion in, 142 
preparation of bed in, 129 
process of repair in, 126 
prognosis of, 125 
reduction in, 131 
removal of clothing in, 131 

of dressings in, 142 
renewal of dressings in, 141 
retention in, 132 
sand-bags in treatment of, 139 
special , lo2 
sjjliuts used in, 133 

binders' board, 134 

felt, 135 

gutta-percha, 135 

metal, 136 

padding of, 138 

paper, 134 

plaster-of-Paris, 136 

retention of, 139 

sole-leather, 134 

wooden, 133 
symptoms of, 122 

physical, 122 

rational, 122 
time for reducing, 141 

required for repair in, 128 
treatment of, 128 
transportation of patient in, 

128 
united with deformity, treat- 
ment of, 147 
ununited, treatment of, 149 
varieties of, 117 

complete, 117 



Fractures, varieties of — 
comminuted, 117 
complicated, 118 
compound, 117 
epiphyseal, 118 
impacted, 117 
simple, 117 
incomplete, 119 
fissured, 119 
partial, 119 
punctured, 119 
weights and pulleys in treat- 
nient of, 140 
lower extremity, 226 
femur, 226 
condyles, knee-joint, 256 
extra-capsular, 237 
great trochanter of, 242 
intra-capsular, 226 
shaft of, 244 
foot, 293 
astragalus, 293 
metatarsus, 296 
08 calcis, 294 
phalanges, 297 
leg, 270 
both bones, 271 
compound, 288 
fibula, 285 
tibia, 280 
patella, 259 
skull, 152 
cranium, 152 
face, 155 

malar bones, 157 
nasal bones, 155 
inferior maxillary bone, 159 
superior maxillary bone, 157 
trunk, 164 

cartilages of the larynx and 

trachea, 165 
costal cartilages, 169 
hyoid bone, 164 
ribs, 170 
sternum, 168 
vertebrse, 166 
upper extremity, 173 
clavicle, 173 
forearm, 196 
botli bones of, 197 
radius, lower extremity, 202 
neck, 199 



NDEX- 



793 



Fractures, upper extremity — 

shaft, 200 
ulna, corouoid process, 210 

lower extrerait}', 212 

olecranon process, 208 

shaft, 211 
hand, 213 
carpus, 214 
metacarpus, 215 
phalanges, 216 
humerus, 183 
condyloid, elbow-joint, 192 
extra-capsular, 185 
intra-capsular, 183 
shaft, 187 

supra-condjdoid, 189 
pelvis, 217 
acetabulum, 224 
coccyx, 219 
ilium, 221 
ischium, 224 
OS innomlnatum, 221 
pubes, 222 
sacrum, 218 
scapula, 181 

Gauze, 15 

antiseptic carbolized, 36 

sublimated, 53 
Glass-wool, 16 
*' Granny" knot, 491 
Guerin's cotton-wool dressing, 56 
Gum tissue, 20 
Gutta-percha tissue, 20 

Handkerchief dressing, 104 

cord, 107 

cravat, 106 

oblong square, 104 

square, 104 

triangle, 105 
Heat, dry, 26 

Incisions, 478 

angular, 478 

curvilinear, 478 

straight, 478 
Instruments for dressing wounds, 

29 
Iodine, 49 
Iodoform, 49 
Irrigation, methods of, 25 
67 



Jute. 15 

salicylated, 47 
sublimated, 53 

Knife, positions of, 476 

Ligatures, 485 

carbolized catgut, 41 

of arteries, 476 
general considerations in, 486 
instruments used in, 484 
of special arteries, 493 
rules for, 491 

silk, carbolized, 41 
Lint, 14 

absorbent, 14 

antiseptic, 14 

jjaper, 14 

patent lint, 14 

Mackintosh, 37 
Maltese cross, 18 

half, 18 
Mayor's system of handkerchief 

dressings, 104 
Moss, 16 

sublimated, 53 
Muslin, 17 

Naphthalin, 51 
Neck, triangles of, 497 
Needles, 48 L 
ligature, 485 

Oakum, 15 

Oil, carbolized, 56 

eucalyptus, 49 
Oiled paper, 20 

silk, 19 
Ointment, boracic, 47 

eucalypttis, 47 

salicj^lic, 47 
Open method of dressing, 58 
Operations antiseptically per- 
formed by carbolic acid, 42 

upon the living and dead sub- 
ject, 482 

Peat, 16 

Plaster jacket, application pf, 

113-116 
Plaster-of-Paris jacket, 113 



794 



NDEX. 



Plasters, 20 

Pocket case of instruments, 31 

Position in treatment of wounds, 

63 
Potassium, permanganate, 52 
Poultices, 23 

astringent, 24 

emollient, 23 

fermenting, 24 

flaxseed meal , 23 

instantaneous, 24 

method of preparing, 23 

rubefacient, 24 

stimulant, 24 
Protective, antiseptic, 41 

Reef-knot, 490 

Rest in treatment of wounds, 62 

Retractors, 575 

Rollers, double-headed, 67 

single-headed, 67 
Rubber cloth, 20 

tubings, 37 

Salicylated cotton-wool, 47 

jute, 47 

ointment, 47 
Salicylic acid, 47 
Sand, 17 
Sawdust, 16 

Sayre's suspension apparatus, 113 
Scissors, 30 
Spatulas, 485 
Splints, 133 

in treatment of wounds, 63 
Sponges, 27 

antiseptic, carbolized, 41 

method of cleansing, 27 
of using, 28 

sublimated, 54 



Spongio-piline, 17 
Steam spray apparatus, 35 
Sublimate, corrosive, 52 
Surgical dressings, 13 
Sutures, 479 

carbolized silk, 41 

continued, 480 

interrupted, 479 

of approximation, 59 

of coaptation, 59 

of relaxation, 59 

quilled, 481 

twisted, 481 

Tenaculum, 575 

Tenax, 15 

Terebene, 52 

Thymol, 48 

Tourniquet, 577 

Tow, 15 

Triangles of the neck, 497 

Waxed paper, 19 
Wool, 15 
cotton-, 14 

Guerin's, dressing, 56 

salicylated, 47 

sublimated, 53 
glass-, 16 
wood-, 16 
Wounds, antiseptic dressings of, 

system of Lister, 35 
cleansing of, 33 
closure of, 479 
dressing of, 32 

articles required in, 32 
instruments used in dressing, 29 
rules for, 34 

Zinc, chloride of, 52 



CATALOGUE No. 7. 



SESSIONS OF 1885-86. 




A CATALOGUE 

OF 

Books FOR STUDENTS; 

INCLUDING A FULL LIST OF 

The ? Qtiiz-Compends? 

AND OF THE 

Manuals and Text-Books 



PUBLISHED BY 



P. BLAKISTON, SON & CO., 

Medical Booksellers, Imporiers and Publishers, 
No. 1012 WALNUT STREET, 

PHILADELPHIA. 



***For sale by all Booksellers, or any book will be sent by mail, 
postpaid, upon receipt of price. Catalogues of books on all branches 
of Medicine, Dentistry, Pharmacy, etc., supplied upon application. 



^QUIZ-COMPENDS? 

A JNEW SERIES OF COMPENDS FOR STUDENTS 

For Use in the Quiz Class and when 

Preparing for Examinations. 

Price of Each, Bound in Cloth, $1.00 Interleaved, $1.25. 



Based on the most popular text-books, and on the lec- 
tures of prominent professors, they form a most complete 
set of manuals, containing information nowhere else 
collected in such a condensed, practical shape. The 
authors have had large experience as quiz-masters and 
attaches of colleges, with exceptional opportunities for 
noting the most recent advances and methods. The 
arrangement of the subjects, illustrations, types, etc., are 
all of the most improved form, and the size of the books 
is such that they may be easily carried in the pocket. 
They are constantly revised, so as to include the latest 
and best teachings, and can be used by students of any 
college. 

No. 1. ANATOMY. (Illustrated.) 

THIRD REVISED EDITION. 
A Compend of Human Anatomy, By Samuel O. L. 
Potter, m.a., m.d., U. S. Army. With 63 Illustrations. 

" The work is reliable and complete, and just what the student 
needs in reviewing the subject for his examinations." — The Physi- 
cian and Surgeon's Investigator , Buflfalo, N. Y. 

" The arrangement is well calculated to facilitate accurate memo- 
rizing, and the illustrations are clear and good." — North Carolina 
Medical yournal. 

Nos. 2 and 3. PRACTICE. 

A Compend of the Practice of Medicine, especially 
adapted to the use of Students. By Dan'l E. Hughes, 
M.D., Demonstrator of Clinical Medicine in Jefferson 
Medical College, Philadelphia. In two parts. 
Part I. — Continued, Eruptive, and Periodical Fevers, 
Diseases of the Stomach, Intestines, Peritoneum, Biliary 
Passages, Liver, Kidneys, etc., and General Diseases, etc. 
Part II. — Diseases of the Respiratory System, Circu- 
latory System, and Nervous System ; Diseases of the 
Blood, etc. 

*^* These little books can be regarded as a full set of 
notes upon the Practice of Medicine, containing the 
Price of each Book, Cloth, $1.00. Interleaved for Notes, $1.25. 



THE ? QUIZ-COMPENDS ?. 



Synonyms, Definitions, Causes, Symptoms, Prognosis, 
Diagnosis, Treatment, etc., of each disease, and includ- 
ing a number of new prescriptions. They have been 
compiled from the lectures of prominent Professors, and 
reference has been made to the latest writings of Pro- 
fessors Flint, Da Costa, Reynolds, Bartholow, 
Roberts and others. 

" It is brief and concise, and at the same time possesses an accu- 
racy not generally found in compends." — ^as. M. French, M.D., 
Ass't to the Prof, of Practice , Medical College of Ohio, Cincinnati. 

" The book seems very concise, yet very comprehensive. . . . 
An unusually superior book." — Dr. E. T. Bruen, Demonstrator 
of Clinical Medicine, University of Pennsylvania. 

" I have used it considerably in connection with my branches in 
the Quiz-class of the University of La." — y. H. Bemiss, New 
Orleans. 

" Dr. Hughes has prepared a very useful little book, and I shall 
take pleasure in advising my class to use it." — Dr. Georg-e W. 
Hall, Professor of Practice, St. Louis College of Physicians and 
Surgeons, 

No. 4. PHYSIOLOGY. Second Ed. 

A Compend of Human Physiology, adapted to the use 
of Students. By Albert P. Brubaker, m.d., De- 
monstrator of Physiology in Jefferson Medical College, 
Philadelphia. Second Ed. Enlarged and Revised. 
" Dr. Brubaker deserves the hearty thanks of medical students 
for his Compend of Physiology. He has arranged the fundamental 
and practical principles of the science in a peculiarly inviting and 
accessible manner. I have already introduced the work to my 
class." — Maurice N. Miller, M.D., Instructor in Practical His- 
tology , formerly Demonstrator of Physiology, University City of 
New York. 

" 'Quiz-Compend' No. 4 is fully up to the high standard estab- 
lished by its predecessors of the same series." — Medical Bulletin, 
Philadelphia. 

" I can recommend it as a valuable aid to the student." — C. N. 
Ellinwood, M.D., Professor of Physiology, Cooper Medical Col- 
lege, San Francisco. 

" This is a well written little book." — London Lancet. 

No. 5. OBSTETRICS. Second Ed. 

A Compend of Obstetrics. For Physicians and Students. 
By Henry G. Landis, m.d., Professor of Obstetrics 
and Diseases of Women, in Starling Medical College, 
Columbus. New Revised Ed. New Illustrations. 
" We have no doubt that many students will find in it a most 

valuable aid in preparing for examination." — The American four- 

nal of Obstetrics. 

" It is complete, accurate and scientific. The very best book of 

its kind I have seen." — y. S. Knox, M.D., Lecturer on Obstetrics, 

Rush Medical College, Chicago. 

Price of each Book, Cloth, $1.00. Interleaved for Notes, $1.25. 



THE ? QUIZ-COMPENDS ?. 



" I have been teaching in this department for many years, and am 
free to say that this will be the best assistant I ever had. It is ac- 
curate and comprehensive, but brief and pointed." — Prof. P. D. 
Yost, St. Louis. 

No. 6. MATERIA MEDIOA. Revised Ed. 

A Compend on Materia Medica and Therapeutics, with 
especial reference to the Physiological Actions of 
Drugs, For the use of Medical, Dental, and Pharma- 
ceutical Students and Practitioners. Based on the New- 
Revision (Sixth) of the U. S, Pharmacopoeia, and in- 
cluding many unofficinal remedies. By Samuel O. 
L. Potter, M.A.,M.D., U. S. Army. 



I have examined the little volume carefully, and find it just 
such a book as I require in my private Quiz, and shall certainly re- 
commend it to my classes. Your Compends are all popular here in 



Washington." — John E. Brackett, M.D., Professor of Materia 
Medica and Therapeutics, Howard Medical College, Washington. 
" Part of a series of small but valuable text-books. . . . While 
the work is, owing to its therapeutic contents, more useful to the 
medical student, the pharmaceutical student may derive much use- 
ful information from it." — N. Y. Pharmaceutical Record. 

No. 7. CHEMISTRY. Revised Ed. 

A Compend of Chemistry. By G. Mason Ward, m.d., 
Demonstrator of Chemistry in Jefferson Medical Col- 
lege, Philadelphia. Including Table of Elements and 
various Analytical Tables. 
" Brief, but excellent. ... It will doubtless prove an admirable 

aid to the student, by fixing these facts in his memory. It is worthy 

the study of both medical and pharmaceutical students in this 

branch." — Pharmaceutical Record, New York. 

No. 8. VISCERAL ANATOMY. 

SECOND EDITION REVISED. 
A Compend of Visceral Anatomy. By Samuel O. L. 
Potter, m.a,, m.d., U. S. Army. With 40 Illustrations. 

*:(.* This is the only Compend that contains fall descriptions of the 
viscera, and will, together with No. i of this series, form the only 
complete Compend of Anatomy published. 

" This work. is very happily arranged, very thorough in practical 
details, and will no doubt prove universally popular with medical 
students." — Medical Herald. 

" I believe it will prove ot great usefulness to the busy teacher or 
student; short, concise helps are always welcome." — Dr. R. JV. 
Hall, Demonstrator of Anatomy, College of Physicians and Sur- 
geons, Chicago. 

" It is a very concise and convenient help to the memory, and 
quite accurate." — Prof. L. B. How, Medical Department, Dart- 
mouth College. 

Price of Each Book, Cloth, $1.00. Interleaved for Notes, $1.25. 



THE ?QUIZ-COMPENDS?. 



No. 9. SURGERY. Second Edition. 

A Compend of Surgery; including Fractures, Wounds, 
Dislocations, Sprains, Amputations and other opera- 
tions, Inflammation, Suppuration, Ulcers, Syphilis, 
Tumors, Shock, etc. Diseases of the Spine, Ear, Eye, 
Bladder, Testicles, Anus, and other Surgical Diseases. 
By Orville Horwitz, a.m., m.d., with 62 Illustra- 
tions. Second Edition. Enlarged and Revised. 

*:i:*This compend has been prepared with great care, from the 
standard authorities on Surgery and from notes taken by the author 
during attendance on lectures by prominent professors. The rapid 
sale of the first edition allowed the addition of much valuable 
matter, besides a thorough revision of the whole book. 

No. 10. ORGANIC CHEMISTRY. 

A Compend of Organic Chemistry, including Medical 
Chemistry, Urine Analysis, and the Analysis of Water 
and Food, etc. By Henry Leffmann, m.d., Pro- 
fessor of Clinical Chemistry and Hygiene in the Phila- 
delphia Polyclinic ; Professor of Chemistry, Penn- 
sylvania College of Dental Surgery ; Member of the 
N. Y. Medico-Legal Society. Cloth. $1.00. 

Interleaved, for the addition of Notes, $1.25. 

" Compact, substantial and exact ; well suited as a remembrancer 
to students." — Pacific Medical and Surgical Jojirnal. 

" This neat, handy and exceedingly useful volume is a valuable 
aid to the student." — PJiarviacentical Record. 

" It contains, in compact form, the most of modern organic and 
medical chemistrj^ essential to the student of medicine, and will be 
of great value in bringing this subject within his grasp." — C. C. 
HcTivard, Prof, of Chemistry , Starling Medical College, Colum- 
bus, Ohio. 

" It has the decided merit of being written in a clear and under- 
standable language." — Dr. y. Sickels, Instructor in Chemistry, 
University Medical College, Nezu York. 

No. il. PHARMACY. 

A Compend of Pharmacy. By Louis Genois, Ph. G., 
Member of the American Pharmaceutical Association. 

.i^g^The ?Quiz Compends ? are adapted to students of any 
college, because they are based upon the text-books in use through- 
out the country". 

i^^They will be found to contain the latest and best informa- 
tion, in such a shape that it may be easily memorized. 
Price of Each Book, Cloth, $1.00 ; Interleaved for Notes, $1.25. 



6 STUDENTS' TEXT-BOOKS AND MANUALS. 

ANATOMY. 

Holden's Anatomy. A manual of Dissection of the Human 
Body. Fifth Edition, enlarged, with Marginal References and 
over 200 Illustrations. Octavo. Cloth, 5.00; Leather, 6.00 

" No student of Anatomy can take up this book without being 
pleased and instructed. Its Diagrams are original, striking and 
suggestive, giving more at a glance than pages of text description. 
* * * The text matches the illustrations in directness of prac- 
tical application and clearness of detail." — Nezv York Medical 
Record. 

Holden's Human Osteology. Comprising a Description of the 
Bones, with Colored Delineations of the Attachments of the 
Muscles. The General and Microscopical Structure of Bone and 
its Development. With Lithographic Plates and Numerous Illus- 
trations. Sixth Edition. 8vo. Cloth, 6.00 
Heath's Practical Anatomy. Sixth London Edition. 24 Col- 
ored Plates, and nearly 300 other Illustrations. Cloth, 5.00 

CHEMISTRY. 

Hartley's Medical Chemistry. A text-book prepared specially 
for Medical, Pharmaceutical and Dental Students. With 40 
Illustrations and Plate of Absorption Spectra. Cloth, 2.50 

Bloxam's Chemistry, Inorganic and Organic, with Experiments. 
Fifth Edition, nearly 300 Illustrations. Cloth, 3.75; Leather, 4.75 

Bowman's Practical Chemistry. Including Analysis. About 
100 Illustrations. Eighth Edition. Cloth, 2.00 

Muter's Practical and Analytical Chemistry. 8vo. Cloth, 2.50 

Richter's Inorganic Chemistry. A text-book for Students. 
Second American, from Fourth German Edition. Translated by 
Prof. Edgar F. Smith, ph.d. 89 Wood Engravings and Colored 
Plate of Spectra, jfust Ready. Cloth, 2.00 

Richter's Organic Chemistry, or Chemistry of the Carbon 
Ccmpounds. Translated by Prof. Edgar F. Smith, ph.d. 
Illustrated, yust Ready. Cloth, 3.00 

Stammer's Chemical Problems, with answers. 

Designed as a help to the teacher in getting up problems, and 
when examining his classes. i2mo. Cloth, .75 

Sutton. Volumetric Analysis. 4th Edition. Illustrated. 

Cloth, 5.00 

Trimble. Practical and Analytical Chemistry. A Complete 
Course in Chemical Analysis, by Henry Trimble, Professor of 
Analytical Chemistry in the Philadelphia College of Pharmacy. 
Illustrated. 8vo. Cloth, 1.50 

49* See pages 2 to ^ for list 0/ ? Quiz-Compends ? 



STUDENTS' TEXT-BOOKS AND MANUALS. 7 

Wolff's Applied Medical Chemistry. By Lawrence Wolff, 
M.D., Demonstrator of Chemistry in Jefferson Medical College, 
Philadelphia. Just Ready. Cloth, 1.50 

CHILDREN. 

Goodhart and Starr. The Diseases of Children. A Manual 
for Students and Physicians. By J. F. Goodhart, m.d., Physi- 
cian to the Evelina Hospital for Children ; Assistant Physician 
to Guy's Hospital, London. American Edition, Revised and 
Edited by Louis Starr, m.d., Clinical Professor of Diseases of 
Children in the Hospital of the University of Pennsylvania ; 
Physician to the Children's Hospital, Philadelphia. Containing 
many new Prescriptions, a List of over 50 Formulae, conforming 
to the U. S. Pharmacopoeia, and Directions for making Artificial 
Human Milk, for the Artificial Digestion of Milk, etc. Just 
Ready. Demi-Octavo, 738 Pages. Cloth, 3.00; Leather, 4.00 

The New York Medical Record says : — "As it is said of some 
men, so it might be said of some books, that they are 'born to 
greatness.' This new volume has, we believe, a mission, particu- 
larly in the hands of the younger members of the profession. In 
these days of prolixity in medical literature, it is refreshing to meet 
with an author who knows both what to say, and when he has said 
it. The work of Dr. Goodhart (admirably conformed, by Dr. Starr, 
to meet American requirements) is the nearest approach to clinical 
teaching, without the actual presence of clmical material, that we 
have yet seen. The details of management so gratefully read by 
the young practiticner are fully elucidated. Altogether, the book 
is one of as great practical working value as we have seen for many 
months." 
Day. On Children. A Practical and Systematic Treatise. 

Second Edition. 8vo. 752 pages. Cloth, 3.00; Leather, 4.00 
Meigs and Pepper. The Diseases of Children. Seventh 

Edition. Bvo. Cloth, 6.00; Leather, 7.00 

DICTIONARIES. 

Cleaveland's Pocket Medical Lexicon. Thirty-first Edition. 
Giving correct Pronunciation and Definition of Terms used in 
Medicine and the Collateral Sciences. . Very small pocket size, 
red edges. Cloth, .75 ; pocket-book style, i.oo 

Longley 's Pocket Dictionary. The Student's Medical Lexicon, 
giving Definition and Pronunciation of all Terms used in Medi- 
cine, with an Appendix giving Poisons and Their Antidotes, 
Abbreviations used in Prescriptions, Metric Scale of Doses, etc. 
24mo. Cloth, I.oo; pocket-book style, 1.25 

Harris' Dictionary of Medical Terminology and Dental Surgery. 
By Prof. Gorgas. Fourth Edition. Cloth, 6.50 ; Leather, 7.50 

i9^ See pages 2 to 5 for list of ? Quiz- Coinpends ? 



8 STUDENTS' TEXT-BOOKS AND MANUALS. 

DENTISTRY. 

Flagg's Plastics and Plastic Filling. 2d Ed. Cloth, 4.00 

Gorgas. Dental Medicine. A Manual of Materia Medica and 
Therapeutics, by Professor F. J. S. Gorgas, m.d., d.d.s., Pro- 
fessor of the Principles and Practice of Dental Science, in Den- 
tal Department, University of Maryland. 8vo. Cloth, 3.00 

Harris' Principles and Practice of Dentistry, Including 
Anatomy, Physiology, Pathology, Therapeutics, Dental Surgery 
and Mechanism. Eleventh Edition, revised and enlarged by 
Professor Gorgas. 744 Illustrations. Cloth, 6.50 ; Leather, 7.50 

Richardson's Mechanical Dentistry. Third Edition. 185 
Illustrations. Svo. ^ Cloth, 4.00; Leather, 4.75 

Stocken's Dental Materia Medica. Third Edition. Cloth, 2.50 

Tomes' Dental Anatomy, Human and Comparative. Sec- 
ond Edition. 191 Illustrations. Cloth, 4.25 

Tomes' Dental Surgery. New Revised Edition. Preparing. 

Taft's Operative Dentistry. A Text-book for Dental Students 
and Practitioners. Fourth Edition. Over 100 Illustrations. 

Cloth, 4.25 ; Leather, 5.00 

EYE. 

Arlt. Diseases of the Eye. Including those of the Conjunc- 
tiva, Cornea, Sclerotic, Iris and Ciliary Body. By Professor 
Fred. Ritter von Arlt. Translated by Dr. Lyman Ware. Illus- 
trated. Svo. Cloth, 2.50 

Higgins. Ophthalmic Practice. A Handbook for Students 
and Practitioners. i6mo. Cloth, .50 

Macnamara. On Diseases of the Eye. Fourth Edition, 
revised, with Marginal References, numerous Colored Plates and 
Diagrams, Wood Cuts and Test Types. Cloth, 4.00 

HYGIENE. 

Parke's Practical Hygiene. Sixth Edition, enlarged. Illus- 
trated. Svo. Cloth, 3.00 
Wilson's Handbook of Hygiene and Sanitary Science. 

Fifth Edition. Revised and Illustrated. Cloth, 2.75 

PHYSICAL DIAGNOSIS. 

Bruen's Physical Diagnosis of the Heart and Lungs. By 
Dr. Edward T. Bruen, Assistant Professor of Clinical Medicine 
in the University of Pennsylvania. Second Edition, revised. 
With new Illustrations. i2mo. Cloth, 1.50 

*:i;*The subject is treated in a plain, practical manner, avoiding 
questions of historical or theoretical interest, and without laying 
special claim to originality of matter, the author has made a book 
that presents to the student the somewhat difficult points of Physi- 
cal Diagnosis clearly and distinctly. 

4®" See pages 2 to S for list of ? Quiz- Compends ? 



STUDENTS' TEXT-BOOKS AND MANUALS. 9 

PRACTICE. 

Roberts* Practice. Fifth American Edition. A Handbook 
of the Theory and Practice of Medicine. By Frederick T. 
Roberts, m.d. ; m.r.c.p., Professor of Clinical Medicine and 
Therapeutics in University College Hospital, London. Fifth 
Edition. Octavo. Cloth, 5.00; Leather, 6.00 

*:;:* This new edition has been subjected to a careful revision. 
Many chapters have been rewritten. Important additions have 
been made throughout, and new illustrations introduced. Recom- 
mended as a Text-book at University of Pennsylvania, Long Island 
College Hospital, Yale and Harvard Colleges, Bishop's College, 
Montreal, University of Michigan, and over twenty other Medical 
Schools. 

" I have become thoroughly convinced of its great value, and 
have cordially recommended it to my class in Yale College." — 
Prof. David P. Smith. 

" I have examined it with some care, and think it a good book, 
and shall take pleasure in mentioning it among the works which 
may properly be put in the hands of students." — A. B. Palmer, 
Prof, o/the Practice of Medicine, University of Michigan. 

" A clear, yet concise, scientific and practical work. It is a capi- 
tal compendiun of the classified knowledge of the subject." — Prof, 
y. Adams Allen, Rush Medical College, Chicago. 

" It is unsurpassed by any work that has fallen into our hands, 
as a compendium for students preparing for examination. It is 
thoroughly practical, and fully up to the times." — The Clinic. 
Aitken's Practice of Medicine. Seventh Edition. 196 Illus- 
trations. 2 vols. Cloth, 12. 00; Leather, 14.00 
Fagge's Principles and Practice of Medicine. A Complete 
Text-book. 2 vols. In Press. 
Tanner's Index of Diseases, and Their Treatment. 8vo. 

Cloth, 3.00 
PHYSIOLOGY. 

Yeo's Physiology. The most Popular Students' Book. By 
Gerald F. Yeo, m.d., f.r.c.s.. Professor of Physiology in King's 
College, London. Small Octavo. 750 pages. Over 300 carefully 
printed Illustrations. ^Vith a Full Glossary and Index. 

Cloth, 4.00;. Leather, 5.00 
" The work will take a high rank among the smaller text-books 
of Physiology."— Pr<2/". H. P. Bozvditch, Harvard Med. School, 
Boston. 

" The brief examination I have given it was so favorable that I 
placed it in the list of text-books recommended in the circular ot 
the University Medical College." — Prof. Lezvis A. Stimpson, 
M. D., 37 East 33d Street, New York. 

" For students' use it is one of the very best text-books in Physi- 
ology." — Prof. L. B. Hotu, Dartmouth Med. College, Hanover, 
N. H. 

4^ See pages 2 to 5 for list of ?Quiz-Compends ? 



10 STUDENTS' TEXT-BOOKS AND MANUALS. 



Kirke's Physiology, nth Ed. lUus. Cloth, 4.00; Leather. 5.00 
Landois' Human Physiology. Including Histology and Micro- 
scopical Anatomy. 2 volumes. Cloth, 10.00 
" So great are the advantages offered bjr Prof. Landois' Text- 
book, from the exhaustive and eminently practical manner in which 
the subject is treated, that, notwithstanding it is one of the largest 
works on Physiology, it has yet passed through four large editions 
in the same number of years. Dr. Stirling's annotations have 
materially added to the value of the work. . . . Admirably 
adapted for the practitioner. . . . With this Text-book at his 
command, no student could fail in his examination." — Lancet. 
Sanderson's Physiological Laboratory. Being Practical Ex- 
ercises for the Student. 350 Illustrations. 8vo. Cloth, 5.00 
Tyson's Cell Doctrine. Its History and Present State. Illus- 
trated. Second Edition. Cloth, 2.00 

PRESCRIPTION BOOKS. 

Wythe's Dose and Symptom Book. Containing the Doses 
and Uses of all the principal Articles of the Materia Medica, etc. 
A new enlarged and revised edition nearly ready. 32mo. 

Cloth, 1. 00; Pocket-book style, 1.25 

Pereira's Physician's Prescription Book. Containing Lists 
of Terms, Phrases, Contractions and Abbreviations used in 
Prescriptions, Explanatory Notes, Grammatical Construction of 
Prescriptions, etc., etc. By Professor Jonathan Pereira, m.d. 
Sixteenth Edition. 32mo. Cloth, i. 00; Pocket-book style, 1.25 

SKIN DISEASES. 

Van Harlingen on Skin Diseases, A Handbook of the Dis- 
eases of the Skin, their Diagnosis and Treatment. By Arthur 
Van Harlingen, m.d., Prof, of Diseases of the Skin in the Phila- 
delphia Polyclinic; Consulting Physician to the Dispensary 
for Skin Diseases, etc. With colored plates. i2mo. Cloth, 1.75 
***This is a complete epitome of skin diseases, arranged in 
alphabetical order, giving the diagnosis and treatment in a concise, 
practical way. Many prescriptions are given that have never been 
published in any text-book, and an article incorporated on Diet. 
The plates do not represent one or two cases, but are composed of 
a number of figures, accurately colored, showing the appearance of 
various lesions, and will be found to give great aid in diagnosing. 
' This new handbook is essentially a small encyclopaedia. * ** 
We heartily commend it for its brevity, clearness and evidently 
careful preparation." — Philadelphia Medical Times. 

" This is an excellent little book, in which, for ease of reference, 
the more common diseases of the skin are arranged in alphabetical 
order, while many good prescriptions are given, together with clear 
and sensible directions as to their proper application." — Boston 
Medical and Surgical yournal. 

Bulkley. The Skin in Health and Disease. By L. Duncan 
Bulkley, Physician to the N. Y. Hospital. lUus. Cloth, .50 

45^ See pages 2 to s for list 0/ ? Quiz- Compends ? 



STUDENTS' TEXT-BOOKS AND MANUALS. U 

SURGERY. 

Heath's Minor Surgery, and Bandaging. New Edition. With 
many Illustrations. In Press. 

Mears' Practical Surgery. A new Edition. In Press . 

Pye's Surgical Handicraft. A Manual of Surgical Manipula- 
tions, Minor Surgery, Bandaging, Dressing, etc., etc. With 
special chapters on Aural Surgery, Extraction of Teeth, Anaes- 
thetics, etc. 208 Illustrations. 8vo. Cloth, 5.00 

Watson on Amputation of the Extremities, and their Compli- 
cations. 2 colored plates and 250 wood cuts. Svo. Cloth, 5.50 

MATERIA MEDICA AND THERAPEUTICS. 

Biddle's Materia Medica. Ninth Edition. For the use of 

Students and Physicians. By the late Prof. John B. Biddle, m.d.. 
Professor of Materia Medica in Jefferson Medical College, Phila- 
delphia. The Ninth Edition, thoroughly revised, and in many 
parts rewritten, by his son, Clement Biddle, m.d., Past Assistant 
Surgeon, U. S. Navy, assisted by Henry Morris, m.d., Demon- 
strator of Obstetrics in Jefferson Medical College. Svo., illus- 
trated. Cloth, 4.00 ; Leather, 4.75 

" The larger works usually recommended as text-books in our 
medical schools are too voluminous for convenient use. This work 
will be found to contain in a condensed form all that is most valuable, 
and will supply students with a reliable guide." — Chicago Med. Jl. 

Merrell's Digest of Materia Medica. Svo. Half Calf, 4.00 

Roberts' Compend of Materia Medica and Pharmacy. By the 

author of " Roberts' Practice." Cloth, 2.00 

" It contains an immense amount of matter." — The National 

Druggist. 

Headland's Action of Medicines. 9th Ed. Svo. Cloth, 3.00 

"Waring. Therapeutics. A Practical Manual. Fourth Edition, 

revised and enlarged. In Press. 

MEDICAL JURISPRUDENCE. 

Reese. A Text-book of Medical Jurisprudence and Toxi- 
cology. By John J. Reese, m.d.. Professor of Medical Juris- 
prudence and Toxicology in the Medical and Law Departments 
of the University of Pennsylvania; Vice-President of the Med- 
ical Jurisprudence Society of Philadelphia ; Physician to St. 
Joseph's Hospital ; Corresponding Member of The New York 
Medico-legal Society. Demi-Octavo. Cloth, 4.00; Leather, 5.00 

4®^ See pages 2 to s for list of ? Quiz-Co7npends ? 



12 STUDENTS' TEXT-BOOKS AND MANUALS. 

Reese's Medical yurisprudence : — Continued. 
" Professor Reese is so well known as a skilled medical jurist, 
that his authorship of any work virtually guarantees the thorough- 
ness and practical character of the latter. And such is the case in 
the book before us. * * * * We might call these the essentials 
for the study of medical jurisprudence. The subject is skeletonized, 
condensed, and made thoroughly up to the wants of the general 
medical practitioner, and the requirements of prosecuting and de- 
fending attorneys. Lf any section deserves more distinction than 
any other, as to intrinsic excellence, it is that on toxicology. This 
part of the book comprises the best outline of the subject in a 
given space that can be found anywhere. As a whole, the work is 
everything it promises, and more, and considering its size, con- 
densation, and practical character, it is by far the most useful one 
for ready reference, that we have met with. It is well printed and 
neatly bound. — New York Medical Record. 

Abercrombie's Students' Guide to Medical Jurisprudence. 
i2mo. Cloth, 2.50 

Mann's Manual of Psychological Medicine, and Allied Ner- 
vous Diseases. Their Diagnosis, Pathology and Treatment, and 
their Medico-Legal Aspects. Illustrated. 8vo. 

Cloth, 5.00; Leather, 6.00 
"Woodman and Tidy's Medical Jurisprudence and Toxi- 
cology. Chromo-Lithographic Plates and 116 Wood engravings. 

Cloth, 7.50; Leather, 8.50 

MISCELLANEOUS. 

Beale. Slight Ailments. Their Nature and Treatment. Illus- 
trated. Svo. Paper cover, .75 ; Cloth, 1.25 

Dulles. Surgical and other Emergencies. Illustrated. Sec- 
ond Edition. i2mo. Cloth, .75 

Fothergill. Diseases of the Heart and Their Treatment. 
Second Edition. Svo. Cloth, 3.50 

Tanner. Memoranda of Poisons. Their Antidotes and Tests. 
Fifth Edition. i2mo. Cloth, .75 

Allingham. Diseases of the Rectum. Fourth Edition. Illus- 
trated. Svo. Paper covers, .75 ; Cloth, 1.25 

OBSTETRICS AND GYNAECOLOGY. 

Byford. The Diseases of Women. By W. H. Byford, a.m., 
M.D., Professor of Gynaecology in Rush Medical College; of 
Obstetrics in the Woman's Medical College ; and Surgeon to the 
Womans' Hospital, Chicago. Third Edition. Over 160 Illus- 
trations. Octavo. Cloth, 5.00; Leather, 6.00 
" The treatise is as complete a one as the present state of our 
science will admit of being written. We commend it to the diligent 
study of every practitioner and student, as a work calculated to in- 
culcate sound principles and lead to enlightened practice."— iVi?w 
York Medical Record. 
^S^ See pages 2 to s for list of ? Quiz- Compends ? 



STUDENTS' TEXT-BOOKS AND MANUALS. 13 

Cazeaux and Tarnier. Obstetrics ; the Theory and Practice 
of. TncUiding the Diseases of Pregnane^' and Parturition, Ob- 
stetrical Operations, etc. By P. Cazeaux, Member of the Impe- 
rial Academy of Medicine, etc. Revised, with additions, by 
S. Tarnier, Prof, of Obstetrics and Diseases of Women and 
Children in the Faculty of Medicine, of Paris. A New Ameri- 
can, from the Eighth French and First Italian Editions. Edited 
and enlarged by Robert J. Hess, m.d., Physician to the North- 
ern Dispensarj', Philadelphia; Member of the College of Physi- 
cians of Philadelphia, etc. iioo pages, 410, with 12 Full-page 
Lithographic plates, 5 of which are Colored, and over 175 Wood 
Engravings. 
Cloth, 8.00; Sheep, 9.00; Half Turkey, 10.00 ; Half Russia, 10.00 
Sold by subscription only. Full information and Four-page 
Circular upon application to the publishers. 

" I have examined this edition of Cazeaux and Tarnier's Theory 
and Practice of Obstetrics, just from the publishing house of 
P. Blakiston, Son & Co., Philadelphia, and pronounce it practical 
and just what is needed by every practitioner. I highly recommend 
the work. It should be prominent in every library." — T. Gaillard 
Thotnas, M. I)., Professor of Gyjicecology in College of Physicians 
and Surgeons, New York. 

Gallabin's Midwifery. A New Manual for Students. Illus- 
trated. In Press. 
Meadows' Manual of Midwifery. Including the Signs and 
Symptoms of Pregnancy, Obstetric Operations, Diseases of the 
Puerperal State, etc. 145 Illustrations. 494 pages. Cloth, 2.00 
Rigby's Obstetric Memoranda. 4th Ed. 32mo. Cloth, .50 
Swayne's Obstetric Aphorisms. For the use of Students 
commencing Midwifery Practice. 8th Ed. i2mo. Cloth, 1.25 

PATHOLOGY AND HISTOLOGY. 

Rindfleisch's General Pathology. For Students and Physi- 
cians. By Prof. Edward Rindfleisch, of Wiirzburg. Trans- 
lated by Wm. H. Mercur, m.d., of Pittsburg, Pa., Edited by 
James Tyson, m.d., Professor of Pathology and Morbid Anatomy 
in the University of Pennsylvania. i2mo. Cloth, 2.00 

Gilliam's Essentials of Pathology. A Handbook for Students. 
47 Illustrations. i2mo. Cloth, 2.00 

*:^* The object of this book is to unfold to the beginner the funda- 
mentals of pathology in a plain, practical way, and by bringing 
them within easy comprehension to increase his interest in the study 
of the subject. Though it will not altogether supplant larger works, 
it will be found to impart clear-cut conceptions of the generally 
accepted doctrines of the day, and to prevent confusion in the mind 
of the student. 

Gibbes' Practical Histology and Pathology. Second Edition. 
i2mo. Qoth, 1.50 

^S" See pages 2 to 5 for list of ? Quiz- Compends ? 



14 STUDENTS' TEXT-BOOKS AND MANUALS. 

THROAT. 

Mackenzie on the Throat and Nose. By Morell Mackenzie, 
M.D., Senior Physician to the Hospital for Diseases of the Chest 
and Throat ; Lecturer on Diseases of the Throat at the London 
Hospital, etc. 
Vol. I. Including the Pharynx, Larj'nx, Trachea, etc., with 

Formulae and 112 Illustrations. Cloth, 4.00 ; Leather, 5.00 

Vol. II. Diseases of the (Esophagus, Nose and Naso-Pharynx, 

with Formulse and 93 Illustrations. Cloth, 3 00; Leather, 4.00 
The two volumes at one time. Cloth, 6.00 ; Leather, 7.50 

" It is both practical and learned ; abundantly and well illustrated ; 
its descriptions of disease are graphic and the diagnosis the best we 
have anywhere seen." — Philadelphia Medical Times. 

Cohen. The Throat and Voice. Illustrated. Cloth, .50 

James. Sore Throat. Its Nature, Varieties and Treatment. 
i2mo. Illustrated. Paper cover, .75; Cloth, 1.25 

URINE AND URINARY ORGANS. 

Acton. The Reproductive Organs. In Childhood, Youth, 
Adult Life and Old Age. Sixth Edition. Cloth, 2.00 

Beale. Urinary and Renal Diseases and Calculous Disorders. 
Hints on Diagnosis and Treatment. i2mo. yust Ready. 

Cloth, 1.75 

Ralfe. Kidney Diseases and Urinary Derangements. 42 Illus- 
trations. i2mo. 572 pages. Just Ready. Cloth, 2.75 

Legg. On the Urine. A Practical Guide. Sixth Edition. 
i2mo. Cloth, .75 

Marshall and Smith. On the Urine. The Chemical Analysis 
of the Urine. By John Marshall, m.d.. Chemical Laboratory, 
University of Pennsylvania, and Prof E. F. Smith, ph.d. With 
Colored Plates. Cloth, i.oo 

Thompson. Diseases of the Urinary Organs. Seventh 
Edition. Illustrated. Cloth, 1.25 

Tyson. On the Urine. A Practical Guide to the Examination 
of Urine. For Physicians and Students. By James Tyson, m.d.. 
Professor of Pathology and Morbid Anatomy, University 
Pennsylvania. With Colored Plates and Wood Engravings. 
Fourth Edition. i2mo. Cloth, 1.50 

Durkee. On Gonorrhoea and Syphilis. Illus. Cloth, 3.50 

J6®=- See pages 2 to 5 for list of ? Quiz-Compends ? 



